Prior Authorization Guidelines Specialist I (CPhT)

About this role

Exemption Status: United States of America (Non-Exempt)

$22.99 - $30.35 - $37.71 “Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description Summary Provide technical and administrative support to the Fee-For-Service (FFS) Medicaid department, primarily by  working  directly  with  the  client  teams,  Clinical  Program  Managers  (CPMs),  Clinical  Specialists,  and Clinical PA Guidelines/Drug Information Management staff to create and support the appropriate administration  of  pharmacy  information  to  include  Medication  Request  Guidelines,  Medication  Request Forms (MRFs), and electronic rules. Support PA in researching PA-related tasks, PA Implementation and perform Prior Authorization processing as needed.

Essential Duties and Responsibilities include the following. Other duties may be assigned. • Create and maintain PA Guidelines documents (content management, file maintenance and archiving, coding and linking in on-line electronic systems). • Provide technical and administrative support to the Clinical Program Manager, Clinical PA Guidelines, Drug  Information  and  PA&UM  staffs  with  the  Medication  Request  process  to  include  formatting, verifying and testing of client Medication Request Guidelines (custom and standard) and formatting/development of Medication Request Forms (MRFs) and electronic rules. • Communicate with clients to obtain client authorization of final documents and ensure timely distribution of documentation to appropriate departments.  • Direct the timely and accurate communication of information to appropriate department staff to include: Medical Exception/Prior Authorization; Medication Request Forms (MRFs); Clinical Document Maintenance, electronic prior authorization and formulary management rules, and associated tools and programs.  • Manage review/QA process for medical exception/prior authorization guidelines prior to implementation and distribution to clients or internal users. • Serve as subject matter expert on processes related to the procedures necessary to ensure effective maintenance of MedImpact Prior Authorization program, and as a resource for  PA guidelines related questions and/or inquiries from both internal and external customers

Supervisory Responsibilities          No supervisory responsibilities                                     Client Responsibilities This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience AA and 2+ years’ experience or equivalent combination of education and experience

Computer Skills Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs.  Experience with Windows based database programs is also required.

Certificates, Licenses, Registrations Must successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory).  Maintains a current Pharmacy License and/or  CPhT  certification without restriction.

Other Skills and Abilities • Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.  • Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication. Self-starter with the ability to work independently and as part of a team. Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Reasoning Ability    • Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.

Mathematical Skills • Ability to add, subtract, multiply, and divide in all units of measure, u

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