Essential Functions:In order to perform this job successfully, an individual must be able to perform each essential function satisfactorily and regular attendance is required. The responsibilities listed below are representative of the primary essential functions required; additional duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Pharmacy Prior Authorization Group

• Research and identify medical policies from applicable insurance carriers as they relate to the specific specialty treatments, procedures, and programs prescribed to patients.
• Identify preauthorization requirements for Humira, Stelara, Cimzia, Xeljanz, Rinvoq, Zeposia, Dupixent, and Skyrizi and complete necessary authorizations or corresponding processes.
• Track process of prior authorization and ensure approvals are being received in a timely manner per department expectations.
• Research and identify medical policies from applicable insurance carriers as they relate to the specific specialty treatments, procedures, and programs prescribed to patient.
• Document all submissions, approvals and denials, and conversations with internal and external customers for inter-departmental communication purposes.
• Analyze prior authorization denials and determine and execute appropriate next steps.
• Analyze and investigate issues found through specialty pharmacies and solve ensuring patient obtains therapies in a timely manner.
• Collaborate with internal departments to identify and implement process improvements to the patient’s financial experience.
• Utilize a data driven approach to identify issues and improve process efficiency while providing ongoing reporting that validates the success of the program.
• Establish and foster relationships with vendors to allow access to programs, data, and other opportunities for collaboration.
• Any and all other duties as assigned.

Medical/ Procedural Prior Authorization Group

• Research and identify payment policies from applicable insurance carriers as they relate to the specific specialty treatments, procedures, and programs prescribed to patient.
• Identify preauthorization requirements for infliximab infusions, iron infusions, and PillCams, and complete necessary authorizations or corresponding processes.
• Research and identify medical policies from applicable insurance carriers as they relate to the specific specialty treatments, procedures, and programs prescribed to patients.
• Track process of prior authorization and ensure approvals are being received in a timely manner per department expectations.
• Document all submissions, approvals and denials, and conversations with internal and external customers for inter-departmental communication purposes.
• Analyze prior authorization denials and determine and execute appropriate next steps.
• Collaborate with internal departments to identify and implement process improvements to the patient’s financial experience.
• Utilize a data driven approach to identify issues and improve process efficiency while providing ongoing reporting that validates the success of the program.
• Establish and foster relationships with vendors to allow access to programs, data, and other opportunities for collaboration.
• Any and all other duties as assigned

Qualification Requirements:The qualifications listed below are representative of the knowledge, skills, and/or abilities required to perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience Requirements:High school diploma or GED required. Associates or Bachelor’s degree is preferred. Must have at least two years experience in a health care or medical office setting.

Certifications/Licenses:None required.

Knowledge, Skills and Abilities:

Working knowledge of:

• Microsoft Office applications
• NextGen (Electronic Medical Record and Practice Management system) and related software preferred
• Insurance payers preferred

Skills:

• Compassionate patient care
• Active listening
• Problem solve, prioritization, and critical thinking
• Attention to detail and organization

Ability to:

• Multitask
• Communicate effectively verbally and in writing
• Work independently as well as in a team environment
• Type proficiently and accurately

Physical Requirements:The physical requirements described here are representative of the physical demands required by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee may be required to walk, sit, stand, reach overhead, and bend to the floor. The employee is regularly required to talk and hear. The employee is required to use dexterity of hands and fingers to operate a computer keyboard, mouse, and other office equipment. Specific vision abilities required by this job include close vision and ability to adjust focus. The employee may be required to lift and transport items up to 10 pounds occasionally. Employees may be required to travel to other company locations due to staffing and training needs.

Working Environment:The working environment described here is representative of the setting which an employee may encounter on the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this position,the employee works in an office environment. The employee is exposed to a computer monitor daily. The employee may be required to travel by automobile and exposed to changing weather conditions while performing the duties of this position. While performing the duties of this position, the employee must be alert to conditions that may impact the safety of patients, employees and visitors.

This job description reflects management’s assignment of key responsibilities; it does not prescribe or restrict the tasks that may be assigned.

MNGI Digestive Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

It is the policy of MNGI Digestive Health to comply with all federal and state laws concerning the employment of persons with disabilities and to act in accordance with regulations and guidance issued by the Equal Employment Opportunity Commission (EEOC). Furthermore, it is the company policy not to discriminate against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training or other terms, conditions and privileges of employment

MNGI’s Culture of Caring

We are caring people, caring for people - working with Compassion, Teamwork, and Integrity

• Compassion: being empathetic and considerate of the needs of our patients and caregivers
• Teamwork: Being accountable for actions, supporting each other in meeting the needs of our patients, and respecting the voice/opinions of others assuming good intent.
• Integrity: Demonstrating honesty, trustworthiness, and transparency whenever you interact with patients or each other.