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Overnight Prior Authorization Representative Express Scripts Jobs in Virginia

Houston Fitness Partners

$10/hr

Willing to become CPR/AED Certified prior to gaining employment and maintain your certification ... employees are legally authorized to work in the United StatesWe provide equal employment ...

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Overnight Prior Authorization Representative Express Scripts information

What is an Overnight Prior Authorization Representative at Express Scripts?

An Overnight Prior Authorization Representative at Express Scripts is responsible for processing and evaluating prescription medication requests that require authorization from insurance providers, primarily during overnight shifts. This role involves reviewing clinical information, communicating with healthcare providers, and ensuring that medications meet insurance guidelines for approval. Representatives also provide customer service to patients, doctors, and pharmacists, helping to resolve issues and explain the prior authorization process. Working overnight means handling requests that come in outside of typical business hours, ensuring 24/7 support for patients and providers.

What are some common challenges faced by Overnight Prior Authorization Representatives at Express Scripts, and how can they be managed?

Overnight Prior Authorization Representatives at Express Scripts often face challenges such as managing high call volumes during off-peak hours, handling urgent medication requests, and working independently with limited on-site supervision. To manage these challenges, representatives should develop strong organizational skills, remain updated on the latest formulary guidelines, and leverage internal resources or escalation protocols for complex cases. Building effective communication with pharmacists, physicians, and other team members—even during overnight shifts—can also help ensure smooth case resolution and maintain high service quality.

What are the key skills and qualifications needed to thrive as an Overnight Prior Authorization Representative at Express Scripts, and why are they important?

To thrive as an Overnight Prior Authorization Representative at Express Scripts, you need a solid understanding of pharmacy benefits, medical terminology, and prior authorization processes, often supported by a high school diploma or equivalent and relevant experience in healthcare or pharmacy. Familiarity with pharmacy management software, claims processing systems, and Microsoft Office Suite is typically required. Attention to detail, strong problem-solving skills, and effective communication are critical soft skills for success in this position. These competencies ensure accurate and timely authorization decisions, safeguard patient access to medications, and uphold compliance with regulatory standards during overnight shifts.
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Clinical Authorization Specialist (Utilization Review)

Clinical Authorization Specialist (Utilization Review)

HALLMARK YOUTHCARE RICHMOND INC

Richmond, VA

$27 - $31/hr

Full-time

Medical, Retirement

Posted 13 days ago

Job description

As a leading Residential Treatment Center in the Greater Richmond area, Hallmark Youthcare treats adolescents with emotional and behavioral challenges triggered by trauma. Treatment is provided in a warm and friendly environment by a group of well-trained, highly motivated staff that take pride in delivering quality care in a fast-paced environment.

We are seeking a detail-oriented Clinical Authorization Specialist (Utilization Review) to join our healthcare team. The ideal candidate will have experience in prior authorizations, insurance verification, utilization review, and medical necessity determinations. This role is responsible for ensuring that medical services are appropriately authorized, clinically supported, and compliant with payer guidelines before, during, and after patient care.

The Clinical Authorization Specialist serves as a liaison between healthcare providers, insurance companies, and patients to facilitate timely approvals while minimizing denials and delays in care.

In addition, this role maintains communication with referral sources (CSA/FAPT/IACCT) to coordinate placement and reimbursement standards for transfers from emergency placements and document submission to Magellan for Medicaid consideration.

Key Responsibilities
  • Master's degree in health services field.
  • Review and process prior authorization requests for medical procedures, diagnostic testing, medications, therapies, and specialty services.
  • Evaluate clinical documentation to determine medical necessity using payer guidelines, evidence-based criteria, and insurance policies.
  • Perform prospective, concurrent, and retrospective utilization reviews.
  • Communicate with physicians, nurses, case managers, and insurance representatives to obtain required clinical documentation.
  • Submit authorization requests and monitor status through payer portals and electronic health record (EHR/EMR) systems.
  • Track authorization approvals, denials, appeals, and expiration dates to ensure continuity of care.
  • Identify incomplete or missing documentation and coordinate with providers to obtain necessary information.
  • Maintain accurate records of all authorization activities, communications, and determinations.
  • Stay current on payer policies, CMS regulations, and utilization management best practices.
  • Assist with appeals and peer-to-peer review coordination when necessary.
  • Meet productivity, turnaround time, quality, and compliance standards.

Required Qualifications

  • High school diploma or equivalent required; Associate's or Bachelor's degree in a healthcare-related field preferred.
  • Minimum of 2 years of experience in prior authorization, utilization review, medical insurance, case management, including admissions.
  • Strong understanding of commercial insurance, Medicare, Medicaid, and managed care plans.
  • Experience working with electronic medical records (EMR/EHR) and payer authorization portals.
  • Excellent organizational, analytical, and problem-solving skills.
  • Strong verbal and written communication abilities.
  • Ability to prioritize multiple tasks in a fast-paced healthcare environment.

Benefits:

Set schedule Monday- Friday 9 am- 5pm

Full benefit package available

Matching 401K

Time off accrued each payroll

Free employee meals