Excellus BCBS
Pharmacy Prior Authorization Technician
Excellus BCBS, Jamestown, New York, United States, 14704
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Job 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 and medical specialty drug reviews. The Technician prepares and interprets cases for utilization management reviews, acts as a content expert for the application systems used, and serves as a resource for staff regarding members’ contract benefits. The role provides leadership in the intake area of the prior authorization process for medications processed through the pharmacy or medical benefit and in processing exception requests that follow standard protocols.
Essential 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 required prior authorization review type and documents relevant medication history.
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 to determine whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy.
Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed.
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.
Responsible for assuring appropriate auth entry across all lines of business and ensuring care management system interfaces to claim processing system.
Performs system testing as required for upgrades and enhancements to the care management system.
Acts as a content expert for prior authorization intake for customers, both internal and external.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot.
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.
Supports medical and pharmacy drug pricing questions, using drug lookup tools such as government sites and other online resources.
Maintains thorough knowledge of health plan contracts, riders, policy statements and procedures.
Performs unit specific workflow processes consistent with corporate medical and administrative policies.
Produces, records, or distributes information for others and tracks and reports department performance against benchmarks.
Prepares and assists in handling correspondence, assuring accuracy and timeliness of processing.
Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services.
Produces at minimum the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
Maintains high regard for member privacy in accordance with corporate privacy policies.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II ( in addition to Level I Accountabilities )
Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
Understands decision tree logic and workflow, and supports writing and implementation of the question set format.
Mentors and assists in onboarding of junior staff & assists with coaching whenever necessary.
Provides consistent positive results of audits.
Works independently in coordinating and collaborating with members and providers.
Manages more complex assignments and detailed coordination between the medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others.
Produces at minimum above team average medication prior-authorization, exception and medical necessity reviews submitted to the plan.
Level III ( in addition to Level II Accountabilities )
Ensures regulatory requirements such as DOH, CMS and Medicaid, relative to patient care are met or exceeded across all lines of business.
Serves as internal auditor within the group to report issues to management and suggest and implement change.
Process management and documentation:
Identifies, recommends and assesses new processes as necessary to improve productivity.
Assists in updating departmental policies, procedures and desk‑top manuals.
Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department.
Functions as a backup to the supervisor for testing and implementation of system upgrades.
Serves as subject matter expert and works directly with the operation and clinical staff to resolve issues and escalated problems.
Independently develops decision tree question set workflows and denial rationale based on policy criteria.
Owns a Desk Level Procedure (DLP) relating to medication prior‑authorization, exception and medical necessity reviews.
Produce the highest level of team medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Assist teammates in obtaining minimum average of medication prior‑authorization, exception and medical necessity reviews for their level of experience.
Minimum Qualifications All Levels
High school diploma with a minimum of two years’ experience in a health‑related field is required; associate’s degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II ( in addition to Level I Qualifications )
Basic understanding and interpretation of medical terminology and diagnosis codes required.
Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
A clear understanding of prescription and medical benefits as it applies to the utilization review process.
Must demonstrate proficient experience with the Microsoft Office suite.
Strong verbal and written communication skills are required.
Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strive to develop and/or refine skills necessary to respond to customers.
Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
Capable of working independently and applying problem solving and analytical abilities.
Level III ( in addition to Level II Qualifications )
Must have 3‑4 years’ experience working with health plan‑based prior authorization and claims processing systems.
Demonstrated ability and understanding to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform systems troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
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 regions as needed.
The ability to hear, understand and speak clearly while using a phone, with or without a headset.
Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Compensation Range(s) Level I Min: $19.22 - Max: $30.76 Level II Min: $20.02 - Max: $33.03 Level III Min: $21.83 - Max: $34.92
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case‑by‑case basis.
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Job 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 and medical specialty drug reviews. The Technician prepares and interprets cases for utilization management reviews, acts as a content expert for the application systems used, and serves as a resource for staff regarding members’ contract benefits. The role provides leadership in the intake area of the prior authorization process for medications processed through the pharmacy or medical benefit and in processing exception requests that follow standard protocols.
Essential 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 required prior authorization review type and documents relevant medication history.
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 to determine whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy.
Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed.
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.
Responsible for assuring appropriate auth entry across all lines of business and ensuring care management system interfaces to claim processing system.
Performs system testing as required for upgrades and enhancements to the care management system.
Acts as a content expert for prior authorization intake for customers, both internal and external.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot.
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.
Supports medical and pharmacy drug pricing questions, using drug lookup tools such as government sites and other online resources.
Maintains thorough knowledge of health plan contracts, riders, policy statements and procedures.
Performs unit specific workflow processes consistent with corporate medical and administrative policies.
Produces, records, or distributes information for others and tracks and reports department performance against benchmarks.
Prepares and assists in handling correspondence, assuring accuracy and timeliness of processing.
Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services.
Produces at minimum the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
Maintains high regard for member privacy in accordance with corporate privacy policies.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II ( in addition to Level I Accountabilities )
Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
Understands decision tree logic and workflow, and supports writing and implementation of the question set format.
Mentors and assists in onboarding of junior staff & assists with coaching whenever necessary.
Provides consistent positive results of audits.
Works independently in coordinating and collaborating with members and providers.
Manages more complex assignments and detailed coordination between the medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others.
Produces at minimum above team average medication prior-authorization, exception and medical necessity reviews submitted to the plan.
Level III ( in addition to Level II Accountabilities )
Ensures regulatory requirements such as DOH, CMS and Medicaid, relative to patient care are met or exceeded across all lines of business.
Serves as internal auditor within the group to report issues to management and suggest and implement change.
Process management and documentation:
Identifies, recommends and assesses new processes as necessary to improve productivity.
Assists in updating departmental policies, procedures and desk‑top manuals.
Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department.
Functions as a backup to the supervisor for testing and implementation of system upgrades.
Serves as subject matter expert and works directly with the operation and clinical staff to resolve issues and escalated problems.
Independently develops decision tree question set workflows and denial rationale based on policy criteria.
Owns a Desk Level Procedure (DLP) relating to medication prior‑authorization, exception and medical necessity reviews.
Produce the highest level of team medication prior‑authorization, exception and medical necessity reviews submitted to the plan.
Assist teammates in obtaining minimum average of medication prior‑authorization, exception and medical necessity reviews for their level of experience.
Minimum Qualifications All Levels
High school diploma with a minimum of two years’ experience in a health‑related field is required; associate’s degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II ( in addition to Level I Qualifications )
Basic understanding and interpretation of medical terminology and diagnosis codes required.
Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
A clear understanding of prescription and medical benefits as it applies to the utilization review process.
Must demonstrate proficient experience with the Microsoft Office suite.
Strong verbal and written communication skills are required.
Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strive to develop and/or refine skills necessary to respond to customers.
Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
Capable of working independently and applying problem solving and analytical abilities.
Level III ( in addition to Level II Qualifications )
Must have 3‑4 years’ experience working with health plan‑based prior authorization and claims processing systems.
Demonstrated ability and understanding to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform systems troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
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 regions as needed.
The ability to hear, understand and speak clearly while using a phone, with or without a headset.
Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Compensation Range(s) Level I Min: $19.22 - Max: $30.76 Level II Min: $20.02 - Max: $33.03 Level III Min: $21.83 - Max: $34.92
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case‑by‑case basis.
#J-18808-Ljbffr