Medication Prior Authorization Representative

The Medication Prior Authorization Specialist plays a key role in ensuring patients receive timely access to prescribed therapies by managing all aspects of the medication prior authorization (PA) process. This position collaborates closely with providers, pharmacies, payers, and care teams to prepare, submit, and track PA requests with accuracy and efficiency. The Specialist ensures strict adherence to payer policies, maintains thorough documentation, and escalates barriers to care when necessary.

Key Responsibilities

Prior Authorization Processing

• Prepare, complete, and submit medication PA requests to insurance plans.
• Review clinical documentation, ensuring all required forms, provider notes, labs, and supporting materials are included.
• Track and manage all PA requests from initial submission through final determination.
• Follow up with payers to verify approvals or address additional requirements.
• Accurately document all PA activities within AthenaOne and payer portals.
  
  

Provider & Pharmacy Coordination

• Communicate with providers to obtain missing information, clarify payer requirements, or discuss alternative therapy options.
• Coordinate with pharmacies to confirm prescription accuracy and prevent delays.
• Notify care teams and patients promptly regarding approvals, denials, and next steps.
  
  

Insurance & Compliance

• Maintain current knowledge of insurance formulary updates, step therapy protocols, and PA criteria.
• Ensure full compliance with HIPAA and organizational policies.
• Maintain documentation that meets internal and external audit standards.
  
  

Patient Support

• Educate patients on expected PA timelines, denial reasons, and next steps such as appeals or alternative therapies.
• Assist in coordinating peer-to-peer reviews when required by payers.
  
  

Workflows & Efficiency

• Meet productivity benchmarks and turnaround time expectations for PA processing.
• Identify workflow gaps or payer-related delays and escalate appropriately.
• Contribute to developing standardized PA workflows, templates, and reference materials.
  
  

Qualifications

• High school diploma or GED.
• 2–3 years of experience processing medication prior authorizations in a healthcare, pharmacy, or payer setting.
• Solid understanding of commercial insurance, Medicare/Medicaid, and formulary requirements.
• Strong attention to detail and excellent documentation habits.
• Proficiency with AthenaOne and familiarity with payer portals.
• Experience in an FQHC, specialty pharmacy, or ambulatory clinical environment.
• Background in medical terminology or pharmacy support (CPhT preferred but not required).
• Experience handling high-volume PA workflows.
  
  

Work-from-Home Device Requirement

• Device: Personal computer with Intel Core i5 or higher, or AMD Ryzen 5 or higher
• Internet: Wired connection with at least 50 Mbps download speed, plus a backup connection (e.g., mobile hotspot or prepaid Wi-Fi)
• Work Environment: Quiet, well-lit space with minimal background noise
  
  

Benefits

• Permanent Work From Home
• Weekly Paychecks
• Fixed Weekends Off
• HMO Reimbursement on your 90th day
• Thriving Company Culture with Complete Autonomy
• Exclusive Specialized Training Programs
• Unlock Your Potential with a Highly Competitive Salary
  
  

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Who are we?

MedCore Solutions is the healthcare division of BizForce, dedicated to supporting U.S.-based healthcare clients through a skilled remote workforce in the Philippines. We specialize in connecting top clinical and administrative talent with reputable healthcare organizations, ensuring high-quality care delivery while providing rewarding work-from-home careers.

Why work for Bizforce?

Bizforce is a global remote workforce solutions company currently partnering with some of the largest Architectural and Engineering firms in the world. If you are looking to advance your career and improve your skills with an industry leader, we encourage you to apply today! Bizforce was founded with one goal – to deliver dependable high-quality skilled labor and business processes to US-based companies at affordable prices. Bizforce has grown rapidly and allows the best talent in PH to work remotely from home with the latest technology and resources. BizForce is proud to partner with PH to deliver qualified, professional workers, giving our Architects and Engineers the ability to have an unbeatable career and work from home.