Manager Prior Authorization Jobs in Rochester, NY

Summary Description:
The Pharmacy Prior Authorization Technician performs functions as permitted by law including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM (utilization management) reviews and determination. In addition, the Technician is the content expert for the applications used to process these requests. The Technician acts as a resource for staff regarding members' specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral/authorization process. This position provides leadership and expertise in the intake area of the prior authorization process for medications processed either through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Essential Responsibilities/Accountabilities:
Level I:
• Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member's benefit.
• Routes cases directly to the pharmacist/medical director for final determination, as directed.
• Issues verbal and written member notification as required.
• Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
• Develops and implements process improvement to increase efficiency in the review process for the clinical staff.
• Works with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria.
• Can point out nuances that may not be readily apparent regarding the request.
• Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
• Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
• Responsible for assuring appropriate auth entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of auth may be required upon case completion.
• Performs system testing as required for upgrades and enhancements to the care management system.
• Acts as a content expert for prior authorization intake for our customers, both internal and external. Serves as department subject matter expert for pharmacy and medical drug authorizations and coverage.
• Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot. Triages issues to the appropriate department for resolution.
• Triages prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
• Provides phone coverage for incoming calls as required to support the UM process. This may include authorization inquiries and information requests, claim inquiries, and other related inquiries. Provides friendly, accurate and timely assistance.
• Supports medical and pharmacy drug pricing questions, and uses drug lookup tools such as government sites, and other online resources.
• Maintains thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff with related inquiries.
• Performs unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
• Produces, records, or distributes information for others. On a periodic basis, tracks and reports department performance against benchmarks.
• Prepares and assists in handling correspondence. Assures accuracy and timeliness of processing.
• Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services examples include Utilization Management, Quality Management and Case Management.
• Produces, at minimum, the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member's benefit.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
Minimum Resource Qualifications:
All Levels:
• High school diploma with a minimum of two years' experience in health-related field is required. Associates degree preferred.
• Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Physical Requirements:
• Ability to work prolonged periods sitting at a workstation and working on a computer.
• Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Typical office environment including fluorescent lighting.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• The ability to hear, understand and speak clearly while using a phone, with or without a headset.