Pharmacy Prior Authorization Agent-Specialty

Major Responsibilities:

• ​​​​​​​Complete insurance verification and eligibility checks. 
• Collect and accurately document initial pre-certification/authorization information if available. Initiates the process of obtaining a required referral/authorization if not obtained. 
• Work assigned Epic work queue, following the department’s workflow process on appropriately transferring, deferring, or removing orders from the work queue. 
• Proactively communicate issues involving customer service and process improvement opportunities to management. 
• Maintains excellent public relations with patients, patients’ families and clinical staff as well as demonstrates a willingness and ability to work collaboratively with others for concise and timely flow of information. 
• Maintains knowledge of and reference materials for Medicare, Medicaid and third-party payer requirements guidelines and policies, insurance plans requiring pre-authorization/referral and a list of current accepted insurance plans. 
• Update the patient, physician's office, and any necessary parties, through multiple methods as appropriate (including telephone, in-basket messaging, and electronic medical record), regarding responses and outcomes of the prior authorizations. 
• Act as a liaison between physician's office, patient, and pharmacy benefit manager to initiate and resolve appeals, as needed. 
• May identify and assist patients with access to internal and external financial assistance programs. 
• May communicate to the patient and/or physician's office when authorization is not obtained, or services are not covered, and explains the potential financial responsibility. Coordinates with patient, clinical team, and assistance programs to secure reimbursement or alternative covered options. 
• Manages incoming and outgoing calls, which may include other Advocate team members, departments, patients, insurance plans and/or copay foundation/assistance programs. 

Licensure, Registration, and/or Certification Required:

• ​​​​​None Required 

Education Required:

• ​​​​​​​​​High School Graduate 

Experience Required:

• ​​Typically requires 1 year of experience in health care, insurance industry, pharmacy, or medical background  

Knowledge, Skills & Abilities Required:

• Demonstrate ability to identify and understand issues and problems. Examines data and draws logical conclusions based on information available 
• Ability to problem solve in a high profile and high stress area 
• Mathematical aptitude, effective communication, and critical thinking skills 
• Ability to prioritize and organize workload 
• Excellent Verbal and written communication skills 
• Demonstrated technical proficiency including experience with insurance authorization/eligibility tools, EPIC, Microsoft Office, Internet browser and telephony systems 

Physical Requirements and Working Conditions:

• ​​​​​​​​​Operates all equipment necessary to perform the job 
• Exposed to normal office environment areas, or remote work area 
• Must have the ability to lift to 10 lbs. occasionally 
• Uses a computer continuously throughout the workday 
• Must be able to sit for extended periods of time  ​  

Preferred Job Requirements

Preferred Education

• No additional education is required 

Preferred Experience

• No additional experience necessary 

Preferred Knowledge/Skills/Abilities

• Knowledge of medical terminology 

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.