Prior Authorization Coordinator

This is a fully remote position, open to applicants in Nevada.

📋 Description

• Review and process prior authorization requests for pharmacy claims.

• Manage prior authorizations received electronically (ePA), via fax, or through requests from providers or members.

• Verify the documentation received and acquire any additional information required by benefit plan parameters under the guidance of a pharmacist.

• Navigate submitted prior authorizations from receipt through clinical review determination utilizing PA navigation software.

• Complete both new and renewal prior authorization requests for specialty and non-specialty medications.

• Communicate with members, pharmacies, and physician offices via telephone, email, and fax as necessary.

• Ensure adherence to benefit plan parameters.

• Educate and assist members in understanding pharmacy benefit plans and the prior authorization process.

• Monitor PA queues and process requests in accordance with company guidelines.

• Investigate, troubleshoot, and resolve issues related to prior authorization requests.

• Receive automated clinical review responses from ePA and conduct manual clinical reviews with pharmacists.

• Draft and dispatch denial letters to providers.

• Transition approved prior authorizations to the appropriate Member or Clinical Care queues.

• Perform additional duties as assigned.

⛳️ Requirements

• Applicants must reside in the Pacific time zone.

• A high school diploma is required.

• A two-year degree in a related field is preferred.

• A demonstrated history of reliable employment.

• Some experience in pharmacy prior authorizations or retail pharmacy settings.

• Strong communication skills when interacting with members, physicians’ offices, and pharmacies.

• Ability to learn and articulate pharmacy benefit plans to benefit holders.

• A proactive approach, with the capability to work diligently through prior authorization queues.

• Ability to operate independently.

• Proficiency in Microsoft Office 365 (Word, Excel, Outlook, etc.).

• Capacity to multitask and adjust priorities according to business needs.

• Strong problem-solving skills, analytical thinking, and attention to detail.

• A desire to learn business processes specific to the Pharmacy Benefit Management (PBM) industry.

🏝️ Benefits

• Part-time position working up to 24 hours per week.

• Fully remote work arrangement.