Job Title : Prior Authorization Representative

Location : Fully remote

Duration : months contract

Job Description :

The Rep I, Clinical Services will also assist with other duties as needed to include but not limited to : outbound calls, reviewing and processing Prior Auth’s received via fax and ePA, monitoring and responding to inquiries via department mailboxes and other duties as assigned by the leadership team.

Work closely with providers to process prior authorization (PA) and drug benefit exception requests for multiple clients or lines of business and in accordance with Medicare Part D CMS Regulations.

Must apply information provided through multiple channels to the plan criteria defined through work instruction. Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases.

Responsible for research and correction of any issues found in the overall process. Phone assistance is required to initiate and / or resolve coverage requests.

Escalate issues to Coverage Determinations and Appeals Learning Advocates and management team as needed. Must maintain compliance at all times with CMS and department standards.

Position requires schedule flexibility and additional cross training to learn all lines of business. Flexibility for movement to different parts of the business to support volume where needed.

Responsibilities :

• Training and working virtually
• Utilizing multiple software systems to complete Medicare appeals case reviews
• Meeting or exceeding government-mandated timelines
• Complying with turnaround time, productivity and quality standards
• Conveying resolution to beneficiary or provider via direct communication and professional correspondence
• Acquiring and maintaining basic knowledge of relevant and changing Med D guidance

Experience :

• At least two years of general business experience that includes problem resolution, business writing, quality improvement, and customer service
• Six months of working in a virtual role where the supervisor is not physically in the same space
• Six months of PBM / pharmaceutical-related work strongly desired
• Required Qualifications :
• Working independently but be self-aware enough to know when to ask for help
• Be technically capable of understanding troubleshooting steps and be able to communicate the results to leaders or IT
• Ability to effectively communicate verbally with members and prescribers while managing multiple software systems
• Accountable and results-driven
• Critical thinker / problem solver
• Receptive to constructive feedback and flexible in adapting to change
• Ability to execute successfully in a deadline-oriented, fast-paced, highly-regulated environment
• Proficient in navigation of multiple computer applications
• Proficient use of keyboard, mouse and ability to navigate workstation monitors
• Ability to type more than WPM.

Skills :

• Prior Authorization
• Medicare and Medicaid
• Call handling experience.

Education :

High School diploma or GED

About US Tech Solutions :

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

To know more about US Tech Solutions, please visit .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Last updated : 2024-07-02