Pharmacy-Prior Authorization

Dupage Medical Group Tinley Park , IL 60477

Posted 3 weeks ago

Hours: Monday-Friday, 8:30am-5:00pm

Location: Lisle, Tinley Park

PRIMARY PURPOSE

The Health Plan Services Pharmacy Prior Authorization Tech supports designated DMG provider sites in obtaining pharmacy prior authorizations for their members in need of medications that are identified by the respective health plan as needing prior authorization and review as well as requests originating from pharmacies. Accountable for processing medication requests with the patient's health plan or pharmacy carrier.

MAJOR RESPONSIBILITIES

  • Data Collection and Documentation

  • Receives and documents, telephonic, and/or electronic requests for medications that require prior authorizations -- source of request is from Primary Care Physicians, Specialists and Ancillary providers

  • Verifies member eligibility and basic benefit coverage levels including obtaining information on coordination of benefits and third party liability as appropriate

  • Utilizes computer resources and available resources both internal and external, to determine provider networks

  • Evaluates each Prior Authorization request to ensure the request including codes, place of service, service type, provider, and all required medical information is available for submission to insurance carrier or approving entity

  • Investigates and obtains from providers, missing medical information required for Prior Authorization submission

  • Maintains accurate and appropriate documentation and follows patient privacy in accordance with HIPPA and DMG policies and procedures

  • Interface with Health Plans and Provider offices

  • Contacts physician offices, pharmacies, review organizations and insurance companies to obtain prior approval requirements, and submit appropriate forms and clinical documentation

  • Works with physician offices to provide ongoing education regarding prior authorization process and requirements

  • Maintains a current working knowledge of all health plan carrier requirements as it relates to requests for prior authorizations and approval path requirements (pre-determinations and peer to peers)

  • Applies clinical knowledge and application of health plan formularies, ICD-9 and CPT coding, as well as medical terminology for appropriate communication with physicians and providers

  • Functions as a resource to physician/provider offices regarding prior authorization requirements, networks, and alternate medication availability as recommended by the patients' health plan

  • Provides source of prior approval request with timely notification of approval or denial decisions through designated communication routes

  • System enter and other functions

  • Performs data entry/processing of prior authorization requests through the EPIC system, and edits Prior authorization notes with appropriate information as outlined per department guidelines and procedures

  • Maintains accurate and detailed prior authorization notes and patient chart documentation entries

  • Resources Team Lead or Supervisor/Manager for review of complex requests and issues

  • Provides input to Team Lead and Supervisor/Manager regarding improvements to operating practices

  • Assists with orientation and training of new staff

MINIMUM EDUCATION AND EXPERIENCE REQUIRED

Level of Education

  • HS Diploma required

  • Associates Degree strongly preferred

Years of Experience

  • 2-3 years of pharmacy technician or medical assistant experience preferred
  • 2+ years pharmacy or health insurance office experience strongly preferred

MINIMUM KNOWLEDGE, SKILLS, AND ABILITIES

  • Medications, generic substitutions/alternatives, office ordering practices regarding medication lab requirements and refills knowledge required

  • Epic system preferred or familiar with other EMR/EHR systems required

  • Understanding of the medical insurance industry and health plans required

  • Proficient computer navigation skills, with advanced Microsoft Office/Outlook and intra/internet experience required

  • Medical Terminology Knowledge required

  • Effective communication skills required

ABOUT DUPAGE MEDICAL GROUP

Join one of the fastest-growing healthcare teams in Chicagoland and experience what superior care and innovation is all about. DuPage Medical Group is the largest independent, multi-specialty physician group in the state, providing physician-directed healthcare focused on quality, efficiency and access. Our team is comprised of more than 700 experienced physicians and 5,500 dynamic individuals who work collaboratively to transform healthcare for the thousands of patients we serve each day. We seek candidates who can help fulfill our mission to enhance the well-being of the patients we serve by providing the highest quality medical care available.

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Pharmacy-Prior Authorization

Dupage Medical Group