Excellus BlueCross BlueShield Inc
Pharmacy Prior Authorization Technician I/II/III
Excellus BlueCross BlueShield Inc - Rochester, New York, United States, 14600
Work at Excellus BlueCross BlueShield Inc
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Overview
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Job Description:
The Pharmacy Prior Authorization Technician performs functions as permitted by law including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM (utilization management) reviews and determination. In addition, the Technician is the content expert for the applications used to process these requests. The Technician acts as a resource for staff regarding members’ specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral/authorization process. This position provides leadership and expertise in the intake area of the prior authorization process for medications processed either through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Essential Responsibilities/Accountabilities:
Level I:
Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Routes cases directly to the pharmacist/medical director for final determination, as directed.
Issues verbal and written member notification as required.
Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
Develops and implements process improvement to increase efficiency in the review process for the clinical staff.
Works with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria. Is able to point out nuances that may not be readily apparent regarding the request.
Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
Responsible for assuring appropriate auth entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of auth may be required upon case completion.
Performs system testing as required for upgrades and enhancements to the care management system.
Acts as a content expert for prior authorization intake for our customers, both internal and external. Serves as department subject matter expert for pharmacy and medical drug authorizations and coverage.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot. Triages issues to the appropriate department for resolution.
Triages prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
Provides phone coverage for incoming calls as required to support the UM process. This may include authorization inquiries and information requests, claim inquiries, and other related inquiries. Provides friendly, accurate and timely assistance.
Supports medical and pharmacy drug pricing questions, and uses drug lookup tools such as government sites, and other online resources.
Maintains thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff with related inquiries.
Performs unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
Produces, records, or distributes information for others. On a periodic basis, tracks and reports department performance against benchmarks.
Prepares and assists in handling correspondence. Assures accuracy and timeliness of processing.
Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services examples include Utilization Management, Quality Management and Case Management.
Produces, at minimum, the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II (in addition to Level I essential responsibilities/accountabilities):
Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
Understands decision tree logic and workflow. Ability to support the writing and implementation of the question set format.
As directed by the policyholder responsible for the quality review of decision tree question set workflow and denial rationale.
Mentors and assists in onboarding of junior staff & assists with coaching whenever necessary.
Provides consistent positive results of audits.
Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health.
Manages more complex assignments and detailed coordination between the medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others in the department.
Produces, at minimum, above team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Level III (in addition to Level II essential responsibilities/accountabilities):
Ensures regulatory requirements such as DOH, CMS and Medicaid, relative to patient care are met or exceeded across all lines of business in the day-to-day work. Serves as internal auditor within the group to report issues to management and suggest and implement change.
Process management and documentation:
Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
Assists in updated departmental policies, procedures and desk-top manuals relative to the functions.
Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department.
Functions as a backup to the supervisor for testing and implementation of system upgrades.
Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems. Own a specialist title designation on the team.
Independently develops decision tree question set work flows and denial rationale based on policy criteria.
Own a Desk Level Procedure (DLP) relating to medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Produce the highest level of team medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Assist teammates in obtaining minimum average of medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit for their level of experience.
Minimum Qualifications:
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
All Levels:
High school diploma with a minimum of two years’ experience in health-related field is required. Associates degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II (in addition to Level I minimum qualifications):
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist required. Proven job-based proficiency in a health care related field can be substituted for the requirement.
Basic understanding and interpretation of medical terminology and diagnosis codes required.
Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
A clear understanding of prescription and medical benefits as it applies to the utilization review process.
Must demonstrate proficient experience with the Microsoft Office suite.
Strong verbal and written communication skills are required.
Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strive to develop and/or refine skills necessary to respond to customers.
Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
Capable of working independently and applying problem solving and analytical abilities.
Level III (in addition to Level II minimum qualifications):
Must have 3 - 4 years’ experience working with health plan-based prior authorization and claims processing systems.
Demonstrated ability and understanding to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform systems troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
Physical Requirements:
Ability to work prolonged periods sitting at a workstation and working on a computer.
Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods of time for business continuity.
Ability to travel across the health plan service regions as needed.
The ability to hear, understand and speak clearly while using a phone, with or without a headset.
The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Compensation Range(s):
N4 Min: 19.22 - Max: 30.76N5 Min: 20.02 - Max: 33.03
N6 Min: 21.83 - Max: 34.92
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
With about 4,000 employees, 31 counties, and serving the needs of over 1.5 million members, you can imagine the gamut of skills it takes to keep our organization growing and our members flourishing. As an internal job seeker, this means growth and development in many directions, divisions, and roles.Take a look at information regarding our hiring process here. https://lifethc.sharepoint.com/sites/HumanCapitalManagement/SitePages/Talent-Acquisition-%26-Onboarding.aspx#hiring-process All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
Job Description:
The Pharmacy Prior Authorization Technician performs functions as permitted by law including the initial level processing and review of prior authorization requests for both pharmacy reviews and medical specialty drug reviews. These reviews are performed utilizing pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM (utilization management) reviews and determination. In addition, the Technician is the content expert for the applications used to process these requests. The Technician acts as a resource for staff regarding members’ specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral/authorization process. This position provides leadership and expertise in the intake area of the prior authorization process for medications processed either through the pharmacy or medical benefit and in processing exception/prior authorization requests that follow standard protocols.
Essential Responsibilities/Accountabilities:
Level I:
Conducts an initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Routes cases directly to the pharmacist/medical director for final determination, as directed.
Issues verbal and written member notification as required.
Reviews and interprets prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required, documents any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
Develops and implements process improvement to increase efficiency in the review process for the clinical staff.
Works with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria. Is able to point out nuances that may not be readily apparent regarding the request.
Contacts pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
Acts as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
Responsible for assuring appropriate auth entry across all lines of business. Ensure care management system interfaces to claim processing system for claim payment. Manual manipulation of auth may be required upon case completion.
Performs system testing as required for upgrades and enhancements to the care management system.
Acts as a content expert for prior authorization intake for our customers, both internal and external. Serves as department subject matter expert for pharmacy and medical drug authorizations and coverage.
Serves as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot. Triages issues to the appropriate department for resolution.
Triages prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
Provides phone coverage for incoming calls as required to support the UM process. This may include authorization inquiries and information requests, claim inquiries, and other related inquiries. Provides friendly, accurate and timely assistance.
Supports medical and pharmacy drug pricing questions, and uses drug lookup tools such as government sites, and other online resources.
Maintains thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff with related inquiries.
Performs unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
Produces, records, or distributes information for others. On a periodic basis, tracks and reports department performance against benchmarks.
Prepares and assists in handling correspondence. Assures accuracy and timeliness of processing.
Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services examples include Utilization Management, Quality Management and Case Management.
Produces, at minimum, the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Level II (in addition to Level I essential responsibilities/accountabilities):
Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
Understands decision tree logic and workflow. Ability to support the writing and implementation of the question set format.
As directed by the policyholder responsible for the quality review of decision tree question set workflow and denial rationale.
Mentors and assists in onboarding of junior staff & assists with coaching whenever necessary.
Provides consistent positive results of audits.
Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health.
Manages more complex assignments and detailed coordination between the medical and pharmacy benefits.
Displays leadership and serves as a positive role model to others in the department.
Produces, at minimum, above team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Level III (in addition to Level II essential responsibilities/accountabilities):
Ensures regulatory requirements such as DOH, CMS and Medicaid, relative to patient care are met or exceeded across all lines of business in the day-to-day work. Serves as internal auditor within the group to report issues to management and suggest and implement change.
Process management and documentation:
Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies.
Assists in updated departmental policies, procedures and desk-top manuals relative to the functions.
Identifies and develops processes and guidelines for performance improvement opportunities for the Utilization Management Department.
Functions as a backup to the supervisor for testing and implementation of system upgrades.
Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems. Own a specialist title designation on the team.
Independently develops decision tree question set work flows and denial rationale based on policy criteria.
Own a Desk Level Procedure (DLP) relating to medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Produce the highest level of team medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit.
Assist teammates in obtaining minimum average of medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the member’s benefit for their level of experience.
Minimum Qualifications:
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
All Levels:
High school diploma with a minimum of two years’ experience in health-related field is required. Associates degree preferred.
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
Level II (in addition to Level I minimum qualifications):
Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist required. Proven job-based proficiency in a health care related field can be substituted for the requirement.
Basic understanding and interpretation of medical terminology and diagnosis codes required.
Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
A clear understanding of prescription and medical benefits as it applies to the utilization review process.
Must demonstrate proficient experience with the Microsoft Office suite.
Strong verbal and written communication skills are required.
Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
Continually strive to develop and/or refine skills necessary to respond to customers.
Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
Capable of working independently and applying problem solving and analytical abilities.
Level III (in addition to Level II minimum qualifications):
Must have 3 - 4 years’ experience working with health plan-based prior authorization and claims processing systems.
Demonstrated ability and understanding to work independently and guide others on complex benefit issues.
Demonstrated ability to independently perform systems troubleshooting, liaise with IT, provider offices, training, and perform other complex utilization management functions at the intake level.
Demonstrated capacity and ability to mentor less experienced staff.
Physical Requirements:
Ability to work prolonged periods sitting at a workstation and working on a computer.
Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
Typical office environment including fluorescent lighting.
Ability to work in a home office for continuous periods of time for business continuity.
Ability to travel across the health plan service regions as needed.
The ability to hear, understand and speak clearly while using a phone, with or without a headset.
The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Compensation Range(s):
N4 Min: 19.22 - Max: 30.76N5 Min: 20.02 - Max: 33.03
N6 Min: 21.83 - Max: 34.92
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.
With about 4,000 employees, 31 counties, and serving the needs of over 1.5 million members, you can imagine the gamut of skills it takes to keep our organization growing and our members flourishing. As an internal job seeker, this means growth and development in many directions, divisions, and roles.Take a look at information regarding our hiring process here. https://lifethc.sharepoint.com/sites/HumanCapitalManagement/SitePages/Talent-Acquisition-%26-Onboarding.aspx#hiring-process All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.