Let’s do great things, together
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.Job Summary:
​​​​​Utilizes the electronic prior authorization (PA) platform to process pharmacy PAs in accordance with clinical criteria and plan benefits while ensuring that the necessary data is inputted into the claims adjudication system for successful claims processing.This a full-time remote position.

Please fill out an application on our company page, linked below, to be considered for this position.

• https://j.brt.mv/jb.do?reqGK=27711343&refresh=true

​​Benefits:

• Medical, Dental, Vision, Pharmacy
• 401K
• FSA
• PTO and Paid Holidays

Schedule

• Full time minimum 7.5 work days with 37.5 work weeks. Weekend availability required.

Primary Functions:

1. Accountable for accurately entering PAs into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members and providers according to corporate policy and government regulations.
2. Responsible for the first pass assessment and evaluation of the PA request prior to higher level review: prepares, assesses, evaluates, and makes initial determination on the PA request with the information received using established criteria.
3. Utilizes critical decision-making skills to interpret formulary coverage and reviews PA requests according to coverage criteria and plan benefits. Prepares necessary documentation and triages requests to the clinical team to determine the final outcome.
4. Interprets contracts (evidence of coverage, handbooks, summary of benefits etc.) and determines actions required.
5. Solves pharmacy plan benefit and formulary issues for members of multiple commercial and ACA plans. Must be able to accurately distinguish member benefit plans and determine member eligibility across varying lines of business and according to varying State requirements.
6. Screens requests for formulary status (e.g., PA required, non-formulary excluded, quantity limits, etc.).
7. Monitors pharmacy turn-around time deadlines and takes action to ensure required timelines are met. Adheres to timelines set forth by the National Committee for Quality Assurance (NCQA)
8. Determines whether additional information is needed from the requesting provider’s office and triages the request to the Rx Assistants.
9. Communicates PA decisions and ensures appropriate feedback and follow-up for all PA requests via electronic interface, fax, telephone, and/or email to requesting providers, members, pharmacies, and internal departments within the promissory timeframes.
10. Supports, tracks, maintains, and ensures data and documentation for member appeals, grievances and complaints are provided within necessary timelines.
11. Interacts with providers and provider offices via electronic interface, fax and/or telephone to gather complete, accurate information to adequately process a PA.
12. Acts as an active team player, responding to the needs of the unit as they arise.
13. Other duties as assigned.

Required Skills:

1. High School diploma or equivalent required. College degree preferred. Equivalent work experience in health care administration, pharmacy, or other health related fields may substitute for the education requirement.
2. Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan.
3. CPhT required for all external applicants. Internal applicants are required to obtain CPhT within one year of hire date.
4. Demonstrated critical decision making, ability to interpret benefit contracts, clinical criteria and Moda Health administrative policies.
5. Demonstrated working knowledge of medical and pharmaceutical terminology and computer skills including Microsoft Office products (proficiency with Word and Excel). Must be able and willing to learn a third-party real-time interactive PBM claims adjudication system, where great attention to detail is imperative.
6. Ability to gain proficiency in Moda internal systems, electronic PA platform and PBM claims processing systems.
7. Typing proficiency of 40 wpm on a computer keyboard.
8. Willingness to work hours necessary to successfully accomplish assigned tasks.
9. Abilities to anticipate needs and multi-task; consistently meet quality and production standards; maintain a high level of confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure.
10. Sound analytical problem solving, decision making, memory retention, and organizational skills.
11. Excellent verbal, written, and interpersonal communication skills including active listening, teamwork, working respectfully with co-workers and members.
12. Preference for fast-paced, production-oriented environment.
13. Must have the ability to work well with Commercial and ACA populations and to resolve pharmacy conflicts in a professional manner.
14. Ability to come to work on time and daily.

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. 
For more information regarding accommodations please direct your questions to HRAdmin@modahealth.com.