Moda Health
About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, we’re focused on building a better future for healthcare by offering outstanding coverage to our members, compassionate support to our community, and comprehensive benefits to our employees. Moda values diversity and inclusion and invites applicants who share our commitment to diversity.
Position Summary The role utilizes the electronic prior authorization (PA) platform to process pharmacy PAs in accordance with clinical criteria and plan benefits. All work is performed full‑time from home.
Pay Range $20.88 – $23.49 per hour, depending on experience. Actual pay is based on qualifications; applicants who do not exceed the minimum qualifications will receive the low end of the range.
Benefits
Medical, Dental, Vision, Pharmacy, Life, & Disability
401(k) – Matching
FSA
Employee Assistance Program
PTO and Company Paid Holidays
Required Skills, Experience & Education
High School diploma or equivalent required; college degree preferred. Equivalent work experience in health care administration, pharmacy, or related fields may substitute for the education requirement.
Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan.
CPhT required for all external applicants. Internal applicants must obtain a CPhT within one year of hire.
Critical decision‑making ability; interpretation of benefit contracts, clinical criteria, and company policies.
Working knowledge of medical and pharmaceutical terminology and computer skills, including proficiency with Microsoft Word and Excel. Ability to learn a third‑party real‑time interactive PBM claims adjudication system.
Typing proficiency of 40 words per minute.
Willingness to work hours necessary to accomplish assigned tasks and meet production standards.
Proven interpersonal, verbal, written, and teamwork skills with a professional business image.
Strong analytical and problem‑solving skills; ability to maintain confidentiality and adapt to change.
Familiarity with commercial and ACA populations and professional resolution of pharmacy conflicts.
Ability to arrive on time and work daily.
Primary Functions
Accurately enter PAs into multiple systems, track requests, and meet timeline requirements for decisions and notifications.
First‑pass assessment and evaluation of PA requests using established criteria.
Interpret formulary coverage, review PA requests, and triage to the clinical team as necessary.
Interpret contracts and determine required actions.
Solve pharmacy plan benefit and formulary issues for multiple commercial and ACA plans.
Screen requests for formulary status (e.g., PA required, non‑formulary exclusion, quantity limits).
Monitor pharmacy turnaround time deadlines and take action to meet required timelines.
Determine if additional information is needed from providers and triage requests to Rx Assistants.
Communicate PA decisions via electronic interface, fax, telephone, and/or email to providers, members, pharmacies, and internal departments.
Track and maintain data and documentation for member appeals, grievances, and complaints within necessary timelines.
Collaborate with providers and provider offices via electronic interface, fax, and/or telephone to gather complete information.
Act as an active team player responding to unit needs as they arise.
Perform other duties as assigned.
Working Conditions & Contact With Others
Internally with own department, primarily with the Clinical team, Operations, and Customer Service; as needed with Appeals, Healthcare Services, Marketing, and Medicare Programs. Externally with Moda members, PBM vendors, providers, provider offices, pharmacists, and pharmacies.
Performs duties in an office environment with extensive keyboard and telephone work; constant sitting. Work may exceed 37.5 hours per week during peak business periods.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other status protected by law. This applies to all terms and conditions of employment.
For more information regarding accommodations, direct your questions to Kristy Nehler and Danielle Baker via our humanresources@modahealth.com email.
Referrals increase your chances of interviewing at Moda Health by 2x.
Get notified about new RX Prior Authorization Coord I jobs in
Portland, OR .
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
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Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, we’re focused on building a better future for healthcare by offering outstanding coverage to our members, compassionate support to our community, and comprehensive benefits to our employees. Moda values diversity and inclusion and invites applicants who share our commitment to diversity.
Position Summary The role utilizes the electronic prior authorization (PA) platform to process pharmacy PAs in accordance with clinical criteria and plan benefits. All work is performed full‑time from home.
Pay Range $20.88 – $23.49 per hour, depending on experience. Actual pay is based on qualifications; applicants who do not exceed the minimum qualifications will receive the low end of the range.
Benefits
Medical, Dental, Vision, Pharmacy, Life, & Disability
401(k) – Matching
FSA
Employee Assistance Program
PTO and Company Paid Holidays
Required Skills, Experience & Education
High School diploma or equivalent required; college degree preferred. Equivalent work experience in health care administration, pharmacy, or related fields may substitute for the education requirement.
Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan.
CPhT required for all external applicants. Internal applicants must obtain a CPhT within one year of hire.
Critical decision‑making ability; interpretation of benefit contracts, clinical criteria, and company policies.
Working knowledge of medical and pharmaceutical terminology and computer skills, including proficiency with Microsoft Word and Excel. Ability to learn a third‑party real‑time interactive PBM claims adjudication system.
Typing proficiency of 40 words per minute.
Willingness to work hours necessary to accomplish assigned tasks and meet production standards.
Proven interpersonal, verbal, written, and teamwork skills with a professional business image.
Strong analytical and problem‑solving skills; ability to maintain confidentiality and adapt to change.
Familiarity with commercial and ACA populations and professional resolution of pharmacy conflicts.
Ability to arrive on time and work daily.
Primary Functions
Accurately enter PAs into multiple systems, track requests, and meet timeline requirements for decisions and notifications.
First‑pass assessment and evaluation of PA requests using established criteria.
Interpret formulary coverage, review PA requests, and triage to the clinical team as necessary.
Interpret contracts and determine required actions.
Solve pharmacy plan benefit and formulary issues for multiple commercial and ACA plans.
Screen requests for formulary status (e.g., PA required, non‑formulary exclusion, quantity limits).
Monitor pharmacy turnaround time deadlines and take action to meet required timelines.
Determine if additional information is needed from providers and triage requests to Rx Assistants.
Communicate PA decisions via electronic interface, fax, telephone, and/or email to providers, members, pharmacies, and internal departments.
Track and maintain data and documentation for member appeals, grievances, and complaints within necessary timelines.
Collaborate with providers and provider offices via electronic interface, fax, and/or telephone to gather complete information.
Act as an active team player responding to unit needs as they arise.
Perform other duties as assigned.
Working Conditions & Contact With Others
Internally with own department, primarily with the Clinical team, Operations, and Customer Service; as needed with Appeals, Healthcare Services, Marketing, and Medicare Programs. Externally with Moda members, PBM vendors, providers, provider offices, pharmacists, and pharmacies.
Performs duties in an office environment with extensive keyboard and telephone work; constant sitting. Work may exceed 37.5 hours per week during peak business periods.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other status protected by law. This applies to all terms and conditions of employment.
For more information regarding accommodations, direct your questions to Kristy Nehler and Danielle Baker via our humanresources@modahealth.com email.
Referrals increase your chances of interviewing at Moda Health by 2x.
Get notified about new RX Prior Authorization Coord I jobs in
Portland, OR .
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr