Prior Authorization Billing Specialist

Prior Authorization Billing Specialist

WHO WE ARE
Polaris Pharmacy Services is an industry leader in Long-Term and Post-Acute Care settings. Founded in 2015, we are locally and independently owned with pharmacies across the country. We are proud to offer competitive benefits, industry pay, and career advancement opportunities to all our team members.

OVERVIEW

The Prior Authorization Specialist/Therapeutic Interchange Pharmacy Technician manages rejected pharmacy claims to ensure maximum payer reimbursement and timely billing. This role involves accurate formulary application and billing for Nursing Homes, Assisted Living Facilities, Group Homes, and Private Pay statements. Strong communication and responsiveness are essential to address customer needs professionally. Building trust and maintaining effective relationships with customers and co-workers is key to success.

RESPONSIBILITIES

• Communicates pharmacy benefit coverage and preferred product to facilities via phone, fax, email, or dashboard.
• Resolves pending therapeutic authorization changes promptly to make the next run or escalate to the Therapeutic Interchange Pharmacist for an alternative intervention.
• Knowledge of Third-Party Billing and Claim resolution and adjudication
• Manage and identify a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to Polaris and its customers
• Research, analyze, and appropriately resolve rejected claims by working with national Medicare D plans, third-party insurance companies, and all state Medicaid plans to ensure maximum payer reimbursement adhering to critical deadlines
• Ensure approval of claims by performing appropriate edits and/or reversals to ensure maximum payer reimbursement
• Contact providers and/or customers as necessary to obtain additional information
• Monitor and resolve revenue at risk associated with payer setup, billing, rebilling, and reversal processes
• Work as a team to identify, document, communicate, and resolve payer/billing trends and issues
• Complete, communicate, and submit necessary payer paperwork, including but not limited to prior authorization forms and manual billing on time
• Review and work convert billing exception reports to ensure claims are billed to accurate financial plans
• Complete billing transactions for non-standard order entry situations as required
• Support training needs
• Prepare and maintain reports and records for processing
• Perform other tasks as assigned.
• Follow all applicable government regulations, including HIPAA
• Comply with departmental policies regarding safety, attendance, and dress code
• Overtime, holidays, and weekends may be required and/or expected
• Conduct job responsibilities following the standards set out in the Company Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards
• Other duties as assigned; Job duties may vary depending on business needs

QUALIFICATIONS

• High School diploma or equivalent required
• Registered Pharmacy Technician experience is required.
• A minimum of one (1) or more years working as a pharmacy technician in a retail environment is required (long-term care pharmacy preferred)
• Framework LTC & General computer knowledge & 10-key Number Entry preferred
• Experience with Cover-My-Meds (preferred)
• Able to read, write, speak, and understand the English language
• Able to retain a large amount of information and apply that knowledge to related situations
• Able to work in a fast-paced environment
• Basic computer knowledge skills required
• Basic math and analytical skills
• Experience with alpha-numeric data entry
• Proficient in Microsoft Word, Excel, and Outlook required
• Customer Service
• Results-oriented
• Good organization/Attention to detail
• Reliable
• Problem solver
• Able to work various shifts and days
• Adaptability to an ever-changing environment

PHYSICAL DEMANDS

The physical demands described here are representative of those that should be met by an employee to perform the essential functions of this job successfully:

• May sit or stand seven (7) to ten (10) hours per day
• The employee is occasionally required to sit; climb or balance; and stoop, kneel, bend, crouch, walk, crawl intermittently
• May be necessary to work extended hours as needed
• May lift and/or move up to 50 pounds
• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role

HOLIDAY & PTO POLICY

• Paid holidays are provided annually, with 6 days offered each year, along with 5 sick days.
• Employees earn up to 10 PTO days each year, with rollover options and milestone bonuses.
• Employees have the option to cash out up to 10 PTO hours each quarter for added financial flexibility.

Please note, because we are a pharmacy most of our locations are open 24 hours a day, 7 days a week and therefore schedules may change as determined by the needs of the business.

BENEFITS – for full-time employees

• Medical, Dental, and Vision insurance
• 401 (k) (available for Part Time & Full Time EEs)
• Company-paid Life Insurance
• Short-term and Long-term disability insurance
• Tuition reimbursement
• Personal Time Off (PTO)
• Competitive pay with annual performance reviews and merit-based raises
• Career growth potential
• Annual on-site voluntary Flu Vaccines
• Employee referral bonus program