Prior Authorization Medication Access Coordinator (PA MAC)

Keystone Advisors is looking for a Prior Authorization Medication Access Coordinator
(PA MAC) to support one of our healthcare clients in Matteson, IL.

Job Summary

The Prior Authorization Medication Access Coordinator (PA MAC) will serve as the primary liaison for ACHN clinics with regard to pharmacy based prior authorizations. The PA MAC is responsible for actively supporting the execution of strategic initiatives process re-design root cause analysis metric/report development and special projects as it relates to authorization denials. The PA MAC will serve as a primary resource on prior authorization requirements.

Typical Duties

• Review and process prior authorization request for medications in the ACHN clinics.
• Verify insurance coverage and ensure all necessary documentation is completed.
• Communicate with medical staff, insurance companies, and specialty pharmacies regarding authorization status.
• Maintain accurate records of authorizations and follow-up as needed.
• Collaborate with medical staff to ensure compliance with policies and procedures.
• Observe and understand prescribing trends within ambulatory clinics.
• Ensure patients receive the services that require prior authorization from insurance carriers by addressing and rectifying rejected claims that require additional documentation and/or Peer to Peer Consultation.
• Assist in resolving any authorization related issues or denials.
• Maintains an audit trail of changes to authorization requirements to assist with root cause analysis and support cause of appeals.
• Analyzes the prior authorization denial report to identify reasons for denials and recommends workflow adjustments as needed, collaborating with affected departments on any workflow or system build issues.
• Maintains a current knowledge related to insurance changes and requirements for prior authorization.
• Improve patient service experience.
• Attends and participates in meetings, as needed.
• Performs other duties as assigned by the Director of Pre-Patient Access.

Minimum Qualifications

• Licensed as a medical professional in the state of Illinois with two (2) years of experience of prior authorization experience/utilization management

• Bachelor’s degree from an accredited college or university with one (1) year of experience prior authorization experience/utilization management

Preferred Qualifications

• Bachelor’s degree in nursing, Health Science, Business or related field from an accredited college or university
• Experience in claims adjudication experience
• Care management or medical insurance experience
• Prior experience using InterQual or Milliman criteria sets

Knowledge, Skills, Abilities and Other Characteristics

• Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Knowledge and proficiency with Microsoft applications and internet-based programs
• Strong interpersonal skills with the ability to establish strong working relationships
• Strong time management skills to prioritize assignments and meet the designated deadlines
• Ability to anticipate, recognize, and meet the needs of patients and families
• Ability to work in a team-based environment to accomplish goals and objectives
• Ability to demonstrate respect and sensitivity for cultural diversity in CCH work force and patient population
• Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representative, physicians, and hospital case managers