Prior Authorization Coordinator Jobs in Riverside, CA

Roles and Responsibilities

• Communicate with patients to obtain information required to process prescriptions, refills, access benefits and apply charges against co-pay cards.
• Investigate and verify insurance benefits and eligibility for pharmacy and medical third-party claims for assigned cases.
• Obtain prior authorizations; initiate requests, track progress, and expedite responses from insurance carriers and other payers, and maintain contact with customers to keep them continuously informed.
• Review for accuracy of prescribed treatment regimen prior to submission of authorization
• Facilitate appeals process between the patient, physician, and insurance company; compose clinical appeals letters based of specific denial reason and patient’s clinical presentation and coordinate appointment of representative document.
• Complete status check with insurance company regarding receipt/outcome of prior authorization and appeal; obtain approval information and activates copay cards based of eligibility and specific drug prescribed.
• Track, report and escalate service issues arising from requests for authorizations, financial assistance or other issues that delay service.
• Notify patients when their prescription has been transferred and follow up with specialty pharmacy to confirm the prescription was received (in some jurisdictions)
• Coordinate verbal transfer by a pharmacist if specialty pharmacy has no record of prescription (in some jurisdictions); confirm with patient that prescription was received from alternate specialty pharmacy.
• Complete a series of assessments mandated by either manufacturer contracts or operations and facilitate patient enrollment with manufacturer Hubs when required.
• Document case activity, communications, and correspondence in computer system to ensure completeness and accuracy of patient contact records.
• Ensure that work activities are conducted in compliance with regulatory requirements and the organization defined standards and procedures, and in a manner that provides the best available level of service and quality.
• Perform or assist with any operations, as required to maintain workflow and to meet business needs.
• Must be able to perform the essential job functions of this position with or without reasonable accommodation.
• Participate in any variety of meetings and work groups to integrate activities, communicate issues, obtain approvals, resolve problems, and maintain specified level of knowledge pertaining to new developments, requirements, and policies.
• Report any misconduct, suspicious or unethical activities to the Compliance Officer
• Participate in surveys conducted by authorized inspection agencies.
• Participate in the pharmacy’s Performance Improvement program as requested by the Performance Improvement Coordinator
• Participate in pharmacy committees when requested.
• Participate in in-service education programs provided by the pharmacy.
• Perform other related duties as assigned by supervisor

• High School Diploma or GED
• Able to read medical charts.
• 1 year of proven work experience in a healthcare
• Previous intake experience preferred but not required.
• Superior telephone customer service skills.
• Healthcare experience with a basic understanding of clinical terms and benefits investigation preferred.
• Previous experience in a call center preferred where there is familiarity with metrics and a high level of accuracy and touches.
• Strong organization skills as well as attention to detail.
• Excellent knowledge of insurance benefit investigation process and techniques.
• Demonstrated ability to manage a range of priorities and meet time commitments.
• Excellent data management software skills with demonstrated adaptability to internal systems.
• Demonstrated strength in listening, oral and written communications in English.
• Pharmacy Technician Certification preferred but not required.
• Any additional training in pharmacy/medical benefit access and requirements, preferred but not required.
• CareTend experience preferred, but not required.

Physical Requirements

Employees in this role must meet certain physical demands to perform the essential functions effectively. Reasonable accommodations will be provided for individuals with disabilities to ensure they can perform these functions. This position involves frequent sitting and requires the ability to communicate effectively through talking and listening. Occasionally, the role requires standing, walking, and using hands to operate objects, tools, or controls. The employee may also need to reach with arms and engage in physical activities such as bending, kneeling, or crouching. Regularly, the employee must lift and move items weighing up to 20 pounds, with occasional lifting of items up to 50 pounds. Visual requirements include the ability to focus, as well as maintain peripheral vision and depth perception.

EEO Statement

We are committed to fostering a diverse and inclusive workplace. As an Equal Employment Opportunity (EEO) employer, we ensure that all employment decisions are based on merit, qualifications, and business needs. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected status. We provide a work environment free from discrimination and harassment, and we celebrate diversity by creating an inclusive environment for all employees.