Home Based Prior Authorization Jobs in Rochester, NY

At our organization, we are driven by a profound dedication to the principle of Meliora - Ever Better. This commitment encompasses our shared values: equity, leadership, integrity, openness, respect, and accountability. Together, we strive to uphold the highest standards in our interactions, ensuring that our community is inclusive and a nurturing environment for everyone.

• Location: 155 Bellwood Dr, Rochester, New York, USA, 14606
• Position Type: Regular
• Employment Status: Full-time
• Weekly Hours: 40
• Department: Pharmacy SMH
• Shift: UR - Day (USA)
• Compensation Range: $21.97 - $29.66 per hour

The stated pay range indicates the minimum and maximum salary for this role. Individual compensation will be determined based on various factors, including market data, education, experience, qualifications, and internal equity considerations.

The Pharmacy Access Representative III (PAR) plays a crucial role in managing medical equipment and supplies, determining coverage, and eliminating obstacles that hinder patients from obtaining their necessary equipment. Key duties include:

• Verifying insurance coverage and determining patient costs.
• Assembling documentation to ensure compliance with payer standards for equipment payment.
• Communicating with prescribers to gather necessary information for insurance claims, including prior authorizations.
• Educating patients with financial needs and coordinating timely equipment delivery.
• Facilitating communication among patients, referral sources, insurance providers, and staff to ensure seamless care.

The PAR will focus on specific service areas, such as hospital discharges and respiratory care, managing daily tasks independently while prioritizing based on patient and pharmacist needs. This role requires sound judgment, sensitivity, and strict adherence to confidentiality policies regarding Private Health Information. The PAR will interact with various individuals within the institution, including pharmacists, pharmacy technicians, and clinical staff, as well as external parties like third-party payers and referring physicians. Success in this role necessitates excellent phone etiquette and a willingness to accept feedback to foster strong collaborative relationships.

• Home Medical Equipment Coordination:
  • Manage referrals and delivery of Home Medical Equipment (HME) to ensure timely service.
  • Troubleshoot insurance issues with referral sources and clinical staff to avoid service interruptions.
  • Act as a liaison among home care coordinators, discharge coordinators, and DME staff to gather accurate coverage information.
  • Assist patients in selecting and purchasing equipment at HME storefronts, providing education on insurance-covered options.
  • Follow up with patients to ensure proper equipment usage and document any issues for management review.
  • Coordinate medical equipment orders with the inventory manager and track ordering trends.
  • Conduct scheduled calls to assess resupply needs and facilitate deliveries.
  • Provide exceptional customer service by directing patient inquiries to the appropriate parties.
  • Monitor and reconcile patient self-pay accounts monthly.
• Financial Management:
  • Maintain knowledge of insurance coverage and requirements for home medical equipment.
  • Evaluate referrals to verify insurance coverage and advise patients on expected out-of-pocket costs.
  • Determine if ordered equipment meets payer coverage requirements and gather necessary information for insurance qualifications.
  • Communicate out-of-pocket costs to patients and identify coverage gaps, utilizing resources for assistance.
  • Serve as a subject matter expert on alternative payment methods.
  • Create and confirm sales orders for equipment and collaborate with service lines for billing information.
  • Analyze high-cost equipment cases to identify the best options for patients based on their circumstances.
  • Work with social services and case management for patient assistance.
• Compliance and Quality:
  • Maintain professionalism in all interactions with staff and patients.
  • Achieve high satisfaction ratings from patients and providers.
  • Report errors through the hospital's reporting system and contribute to quality improvement efforts.
  • Assist with payer audits and ensure timely completion of required documentation.
  • Support the training of new team members in designated clinical areas.
  • Perform related duties as needed, including tasks associated with the Intake Pharmacy Access Representative.
• Prior Authorization Management:
  • Stay informed about current policies from major payers regarding prior authorization (PA) requirements.
  • Collaborate with prior authorization coordinators and patient care staff to ensure compliance before requesting PA.
  • Submit and monitor prior authorization requests promptly.
  • Document and track all prior authorization requests to enhance patient experience and prevent treatment delays.

• Must be at least 18 years old at the time of application.
• Associate’s degree in a Medical, Secretarial, or related field with 4 years of relevant experience required.
• Alternatively, an equivalent combination of education and experience is acceptable.

• Ability to work independently with minimal supervision.
• Strong communication, problem-solving, and professional presentation skills.
• Demonstrated customer relations abilities.
• Capacity to manage multiple tasks accurately under pressure while maintaining professionalism.

• Completion of an ASHP-accredited training program or equivalent experience as a pharmacy technician is preferred.
• Certification from a nationally recognized pharmacy technician certification program (currently PTCB) and ongoing education requirements are preferred.

Our organization is dedicated to fostering an inclusive and welcoming culture that aligns with our mission to Learn, Discover, Heal, Create – and Make the World Ever Better. We uphold our values by ensuring non-discrimination based on age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by law. This commitment extends to all aspects of our policies, admissions, employment, access, and recruitment practices.