Prior Authorization Guidelines Specialist I

Summary

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join their team. The Prior Authorization Guidelines Specialist I will provide technical and administrative support to the Fee-For-Service Medicaid department, focusing on the administration of pharmacy information and supporting prior authorization processes.

Responsibilities

• 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

Skills

• AA and 2+ years' experience or equivalent combination of education and experience
• Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs
• Experience with Windows based database programs
• 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
• 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
• 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
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
• Ability to compute rate, ratio, and percent and to draw and interpret bar graphs
• Ability to read and comprehend simple instructions, short correspondence, and memos
• Ability to write simple correspondence
• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization

Qualifications

Must Haves

• AA and 2+ years' experience or equivalent combination of education and experience
• Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs
• Experience with Windows based database programs
• 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
• 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
• 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
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
• Ability to compute rate, ratio, and percent and to draw and interpret bar graphs
• Ability to read and comprehend simple instructions, short correspondence, and memos
• Ability to write simple correspondence
• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization

Benefits

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus