The primary role Prior Authorization Specialist is to serve as the liaison between the customer and the client as an access and reimbursement specialist. Individuals who succeed in this role will demonstrate excellent Clinical knowledge including justifying the rationality of drug usage and effective interpretation of clinical charts.
Roles and responsibilities:
- Initiating an electronic-Prior authorization request for the required drug
- Suggesting formulary/cheaper alternatives for expensive drugs
- Handling Phone &paper PA requests and manual PA requests for the corresponding drug
- Probing for any serious drug interactions with the requested drug
- Documenting appropriate lab values, culture reports, and other associated medical data as needed for the requesting drug from LTC/NSG/AL facility
- Contacting Long Term care facilities for clinical information supporting the PA requests such as diagnosis, assessment and the medication orders etc.
- Appealing for a denied request with appropriate clinical information and documentation.
- Processing the expedited PA requests within the specified time frame.
- Knowledge of Drug classification, step therapy management, brand & generics, and Drug-Drug Interactions
- Pharmacy graduate (M.Pharmacy/Doctor of Pharmacy)
- Knowledge of sig codes
- Knowledge of MS Outlook, MS Word, MS Excel & Internet Explorer
- Strong prioritizing & organizational skills
- Ensure compliance with HIPAA regulations and requirements.