Prior Authorization Specialist

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

📋 Description

• Oversee and assess a portfolio of rejected pharmacy claims.

• Investigate, analyze, and resolve rejected claims involving Medicare Part D plans, third-party insurers, and state Medicaid programs.

• Execute edits and reversals to obtain claim approvals and optimize payer reimbursement.

• Reach out to providers and facility representatives to gather additional information.

• Monitor and address revenue risks associated with payer setup, billing, rebilling, and reversal processes.

• Identify, document, communicate, and resolve trends and issues related to payers and billing as part of a collaborative team.

• Complete, communicate, and promptly submit prior authorization forms.

• Assist with training requirements.

• Prepare and maintain processing reports and records.

• Adhere to applicable government regulations, including HIPAA.

• Follow departmental policies regarding safety, attendance, and dress code.

• Conduct duties in accordance with the company's Code of Business Conduct and Ethics, policies, Corporate Compliance Agreement, federal and state legislation, and professional standards.

• Perform additional assigned tasks as needed based on business requirements.

⛳️ Requirements

• High School diploma or equivalent is mandatory.

• Preferred: At least one year of experience as a pharmacy technician in a retail setting; experience in long-term care pharmacy is advantageous.

• Familiarity with Framework LTC and general computer skills is preferred.

• Preferred: Proficiency in 10-key number entry.

• Must be able to read, write, speak, and understand English.

• Ability to retain substantial information and apply it to relevant situations is essential.

• Capacity to thrive in a fast-paced work environment.

• Basic computer knowledge and skills are required.

• Fundamental math and analytical capabilities are necessary.

• Experience with alphanumeric data entry is desired.

• Proficiency in Microsoft Word, Excel, and Outlook is required.

• Strong customer service skills are essential.

• Results-oriented mindset.

• Excellent organizational skills and attention to detail.

• Reliability and problem-solving abilities are crucial.

• Flexibility to work various shifts and days.

• Adaptability to a constantly changing environment.

• Willingness to work overtime, holidays, and weekends may be required.

• May need to sit or stand for seven to ten hours daily.

• Ability to lift and/or move up to 30 pounds.

• Compliance with HIPAA, applicable laws, company policies, and professional standards is mandatory.

🏝️ Benefits

• Paid holidays: 6 days per year.

• 5 sick days per year.

• Up to 10 PTO days per year, with rollover options and milestone bonuses.

• Option to cash out up to 10 PTO hours each quarter.

• Medical, Dental, and Vision insurance available.

• 401(k) plan available for both part-time and full-time employees.

• Company-paid life insurance.

• Short-term and long-term disability insurance provided.

• Tuition reimbursement program.

• Competitive compensation with annual performance evaluations and merit-based raises.

• Opportunities for career advancement.

• Annual on-site voluntary flu vaccinations offered.

• Employee referral bonus program available.