Methodist Le Bonheur Healthcare
Hospital Pharmacy Authorization Specialist
Methodist Le Bonheur Healthcare, Memphis, Tennessee, us, 37544
Hospital Pharmacy Authorization Specialist
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Hospital Pharmacy Authorization Specialist
role at
Methodist Le Bonheur Healthcare .
We strive to be an employer of choice and establish a reputation for being a talent‑rich organization where associates can grow their career caring for others. For over a century, we have served the health care needs of the people of Memphis and the Mid‑South.
The Hospital Prior Authorization Specialist coordinates and secures prior authorizations for inpatient and outpatient hospital services in accordance with payer requirements and regulatory standards. This position ensures all necessary approvals are obtained to support timely patient care, optimize reimbursement, and reduce the risk of claim denials. The Specialist collaborates closely with clinical staff and insurance providers to maintain compliance, accuracy, and operational efficiency.
Responsibilities
Precertify eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity.
Review clinical information submitted by medical providers to evaluate the necessity, appropriateness, and efficiency of prescription medication use.
Assist with patient assistance and grant coordination for patients in outpatient pharmacies from designated areas.
Analyze information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verify physician orders and determine CPT, HCPCS, and ICD‑10 codes for proper Prior Authorization.
Contact insurance companies and third‑party administrators to gather information and organize workflow based on the requested procedure.
Collect, read, and interpret medical documentation to determine if appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
Serve as the primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establish and maintain rapport with providers and provide ongoing education regarding pre‑certification protocols.
Communicate information and act as a resource to Patient Access, Case Management, and other departments regarding contract guidelines and pre‑certification requirements.
Research denials or problematic accounts as necessary. Identify trends and root causes of issues and recommend resolutions for future processes.
Education / Formal Training Requirements
High School Diploma or Equivalent
Work Experience Requirements
3–5 years of experience in pharmacy (clinical, hospital, outpatient, or specialty)
Licenses And Certifications Requirements
See Additional Job Description.
Knowledge, Skills And Abilities
Basic understanding of prescription processing flow; expertise in utilizing EMRs to document clinical criteria required for third‑party approval.
Knowledgeable of medical terminology, drug nomenclature, symbols, and abbreviations associated with pharmacy practice.
Strong attention to detail and critical thinking skills.
Effective speaking and communication skills with patients, associates, and other health professionals.
Ability to diagnose situations and recommend solutions.
Experience with a computerized healthcare information system; proficiency with Microsoft Word.
Excellent verbal and written communication skills.
Supervision Provided by this Position
There are no lead or supervisory responsibilities assigned to this position.
Physical Demands
Activities may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
Must have good balance and coordination.
Light work – up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
Requires close visual acuity for tasks such as preparing and analyzing data, transcribing, and extensive reading.
No substantial exposure to adverse environmental conditions; functions typically performed in standard office or administrative settings.
Our associates are passionate about what they do, the service they provide, and the patients they serve. We value family, teamwork, and a Power of One culture that requires commitment to the highest standards of care and unity.
Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.
#J-18808-Ljbffr
Hospital Pharmacy Authorization Specialist
role at
Methodist Le Bonheur Healthcare .
We strive to be an employer of choice and establish a reputation for being a talent‑rich organization where associates can grow their career caring for others. For over a century, we have served the health care needs of the people of Memphis and the Mid‑South.
The Hospital Prior Authorization Specialist coordinates and secures prior authorizations for inpatient and outpatient hospital services in accordance with payer requirements and regulatory standards. This position ensures all necessary approvals are obtained to support timely patient care, optimize reimbursement, and reduce the risk of claim denials. The Specialist collaborates closely with clinical staff and insurance providers to maintain compliance, accuracy, and operational efficiency.
Responsibilities
Precertify eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity.
Review clinical information submitted by medical providers to evaluate the necessity, appropriateness, and efficiency of prescription medication use.
Assist with patient assistance and grant coordination for patients in outpatient pharmacies from designated areas.
Analyze information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verify physician orders and determine CPT, HCPCS, and ICD‑10 codes for proper Prior Authorization.
Contact insurance companies and third‑party administrators to gather information and organize workflow based on the requested procedure.
Collect, read, and interpret medical documentation to determine if appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
Serve as the primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establish and maintain rapport with providers and provide ongoing education regarding pre‑certification protocols.
Communicate information and act as a resource to Patient Access, Case Management, and other departments regarding contract guidelines and pre‑certification requirements.
Research denials or problematic accounts as necessary. Identify trends and root causes of issues and recommend resolutions for future processes.
Education / Formal Training Requirements
High School Diploma or Equivalent
Work Experience Requirements
3–5 years of experience in pharmacy (clinical, hospital, outpatient, or specialty)
Licenses And Certifications Requirements
See Additional Job Description.
Knowledge, Skills And Abilities
Basic understanding of prescription processing flow; expertise in utilizing EMRs to document clinical criteria required for third‑party approval.
Knowledgeable of medical terminology, drug nomenclature, symbols, and abbreviations associated with pharmacy practice.
Strong attention to detail and critical thinking skills.
Effective speaking and communication skills with patients, associates, and other health professionals.
Ability to diagnose situations and recommend solutions.
Experience with a computerized healthcare information system; proficiency with Microsoft Word.
Excellent verbal and written communication skills.
Supervision Provided by this Position
There are no lead or supervisory responsibilities assigned to this position.
Physical Demands
Activities may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
Must have good balance and coordination.
Light work – up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
Requires close visual acuity for tasks such as preparing and analyzing data, transcribing, and extensive reading.
No substantial exposure to adverse environmental conditions; functions typically performed in standard office or administrative settings.
Our associates are passionate about what they do, the service they provide, and the patients they serve. We value family, teamwork, and a Power of One culture that requires commitment to the highest standards of care and unity.
Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.
#J-18808-Ljbffr