Flrx Intake Coordinator I-014474

Excellus Bluecross Blueshield Fairport , NY 14450

Posted 3 months ago

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.

Summary

Under the general direction of the Assigned Management, the Intake Coordinator 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 FLRX pharmacy management drug policies and procedures. This position accurately prepares and interprets cases for UM reviews and determination. In addition, the Coordinator is the content expert for the applications used to process these requests. The Intake Coordinator 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 FLRX exception/prior authorization requests that follow standard protocols.

Essential Responsibilities/Accountabilities

Primary Focus

  • Prescription Drug Benefit
  • Conducts an initial level medication prior-authorization, exception and Rx/medical necessity reviews submitted by prescribers and routed through the FLRx Drug Prior Authorization system to determine coverage under the member's benefit.

  • Routes cases directly to the medical director for final determination, as directed.

  • Reviews and interprets prescription 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 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 in order to optimize the member experience.

  • Acts as a lead troubleshooter for the pharmacy help desk and POS customer service representatives to coordinate pharmacy claims with prior authorization information on file or needed for the member.

  • Responsible for updating the prior authorization system with the GPI's, denial reasons, mednotes and general updates across all lines of business. This requires working closely with the clinical staff to obtain sign off and approvals for changes/updates and notifying the clinical/intake staff of these changes.

  • Performs system testing as instructed by IT as required for upgrades and enhancements to the Lotus Notes database.

  • Acts as a content expert for prior authorization intake for our customers, both internal and external. Serves as go-to person for the customer service based pharmacy intake unit for questions regarding performing the intake process.

  • Serves as lead liaison for the prior authorization process and its interface to the Point of Sale system to troubleshoot. Triages issues to the appropriate department for resolution.

  • Triages prior authorization workflow on a daily basis by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping the manager aware of issues related compliance mandated time frames for review completion.

  • Supports the Medical Specialty Drug unit to provide backup support for their systems including all medical claims systems and Careplanner. Provides phone support for this unit.

Primary Focus

  • Medical Benefit:
  • Performs intake level review for Medical Specialty Drug and does predefined administrative approvals for the unit.

  • Suggests and implements process improvements for the Medical Specialty Drug unit when identified.

  • Maintains thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures in order 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

  • Serves as the primary contact for provider contacts, including authorization and information requests, claim inquiries, and other related inquiries. Provides friendly, accurate, and timely assistance.

  • Responds to requests related to authorization for medical drug, medical drug claims review and related benefit requests

  • Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Examples: Utilization Management, Quality Management, and Disease Management

  • Acts as backup in support of the UM management of the Pharmacy benefit.

  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and 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.

Minimum Qualifications

Note of Classification

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.

  • High school education required with a minimum of two years' experience in health related field (All levels)

  • Pharmacy Technician certification (CPhT) strongly preferred (level I).

  • Pharmacy Technician certification (CPhT) required if primary job function is pharmacy benefit based (level II).

  • If primary job function is a Medical Benefits focus, LPN, Medical Assistant/Technologist background with a minimum of 1 year recent experience working in Health Plan Customer Service UM role preferred (level I).

  • For promotion to level II, NYS LPN Licensure, Medical or Pharmacy Certification is required.

  • Basic understanding and interpretation of medical terminology and diagnosis codes required.

  • Basic understanding of drug classes and therapeutic interchange as described in the FLRx drug policies.

  • A clear understanding of prescription and medical benefits as it applies to the utilization review process.

  • Must demonstrate proficient experience in the use of a computer. Examples-creating documents, database entry, Microsoft Word, Excel, Internet and email.

  • Strong communication skills are necessary including written, verbal and telephone.

  • Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when dealing 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 the customer.

  • 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.

Physical Requirements

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


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Flrx Intake Coordinator I-014474

Excellus Bluecross Blueshield