Prior Authorization Rep

Prime Therapeutics LLC Omaha , NE 68102

Posted 4 months ago

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Prior Authorization Rep

Job Description

The Associate Clinical Operations Technician is responsible for processing, communicating, documenting and tracking requests for formulary exceptions, prior authorizations, quantity exceptions, and brand override for delegated utilization management (UM) products and services.


  • Review criteria to determine if the request can be approved

  • Accurately enter Prior Authorization in claims system to ensure appropriate claims will adjudicate

  • Respond to completed requests by creating written communication of the clinical outcome to the member and the member's physician within client specific turnaround times

  • Research and respond to calls and emails

  • Perform outreach to pharmacies and physician's offices related to the department process across multiple clients to obtain all necessary information related to UM requests, including occasional member assistance

  • Provide all relevant clinical information specific to a UM request to a department Pharmacist and the Physician

  • Manage work queue and volumes to meet client specific turnaround times

  • Other duties as assigned

  • Commercial: Responsible to be proficient in one area (i.e., intake, research, etc.); area assignment is based on department need

  • Government Programs: Responsible to be proficient in single review, approval/denial, etc.

Minimum Qualifications

  • High school diploma from an accredited school or equivalent GED

  • Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications

  • Strong verbal and written communication skills, interpersonal skills, and attention to detail

  • Demonstrated organizational and time-management skills

  • Willingness and ability to learn internal systems/processes/programs as needed

  • Ability to work overtime, weekends and holidays on a rotating basis as needed

  • Basic math skills and general PC knowledge including Microsoft Office, Internet, and email.

  • Ability to work a flexible schedule to accommodate business needs

Preferred Qualifications

  • Associate's degree in business or related area of study, or equivalent combination of education and/or relevant work experience

  • National Pharmacy Technician Certification through PTCB or ExCPT (CPhT)

  • PBM/health care experience

Minimum Physical Job Requirements

  • Constantly required to sit, use hands to handle or feel, talk and hear

  • Frequently required to reach with hands and arms

  • Occasionally required to stand, walk and stoop, kneel, and crouch

  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure

  • Reports to Supervisor in the Clinical Review department

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage qualified minority, female, veteran, disabled, and other diverse candidates to apply and be considered for open positions.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Authorization Review Nurse (Rn) Remote Work Available

Wisconsin Physicians Service Insurance Corporation

Posted 2 weeks ago

VIEW JOBS 10/5/2019 12:00:00 AM 2020-01-03T00:00 Role Summary The Authorization Review Nurse reviews medical cases to determine authorizations for veterans and their families. In addition, the Authorization Review Nurse will provide education and customer support to providers and beneficiaries. Remote work offered in the states of Wisconsin, Illinois, and Nebraska ONLY In this role you will: * Review 20 to 25 individual patient medical records and gather necessary information to determine medical necessity based on Interqual Criteria for skilled cares (SNF), Mental Health, Adjunctive Dental, Transplants, Cancer Clinical Trials, Hospice, and Extended Care Health Option (ECHO). * Make determinations within 2 to 5 business days after all information is received to meet required standards. * Build template letter and communicate with provider for needed records/decisions. * Gather information and organize it for the Medical Advisor review when medical necessity is not determined at specific level. * Respond to emails, faxes, and phone calls from providers, beneficiaries, and other departments to address benefit eligibility questions and provide education of TRICARE for Life policy and procedures. * Advocate for Veterans and their families regarding benefits with TRICARE for Life. * Research and apply current medical practices in determination process. * Assist in development and ongoing revision of managed care policies, procedures, and letters. This role could be a good fit if you: * Thrive in a fast-paced environment * Tired of traveling and enjoy working from home * Process improvement minded * Have prior case management experience You'll benefit from this experience by: * Serving our veterans * Learning how authorizations are approved * Gaining exposure to MS Dynamics (new CRM coming next year!) * Are looking for regular hours with no weekend, holiday, or on-call work You need to have: * U.S. citizenship is required for this position due to Department of Defense restrictions. * Registered Nurse * 4 or more years nursing experience, with two (2) years in a component of managed care * Ability to train on-site for 2 to 4 weeks * Wisconsin, Illinois, or Nebraska residence for remote work We also prefer: * Certified Case Manager (CCM) * BSN Your Team: * You'll work with a team of 3 peers, Medical Lead, and Manager. Compensation and Benefits * Eligible for annual Performance Bonus Program * 401(k) with dollar-per-dollar match up to 6% of salary * Competitive paid time off * Health and dental insurance start DAY 1 * Vision insurance * Flexible spending, dependent care, and health savings accounts * Short- and long-term disability, group life insurance * Innovative professional and cognitive development programs Who We Are WPS Health Solutions is an innovator in health insurance and a worldwide leader in claims administration, serving millions of beneficiaries in the United States and abroad. Founded in 1946, WPS offers health insurance plans for individuals, families, and seniors, and group plans for small and large businesses. We are a world-class claims processor and program administrator for the government's Medicare program. And we manage benefits for millions of active-duty and retired military personnel and their families. WPS has been named one of the World's Most Ethical Companies® by the Ethisphere® Institute for 10 years in a row. Learn more about WPS. Our Purpose and Values Our purpose is to make healthcare easier for those we serve. Click Here Our values – Customer Focused, Individual Responsibility, Mutual Respect, and Driven & Passionate – are the core of who we are and how we conduct business every day. Links and descriptions for: Health Insurance WPS Health Insurance offers high-quality health insurance plans for individuals and families, Medicare supplement plans for seniors, and group health plans for businesses of every size. Military and Veterans Health WPS Military and Veterans Health administers claims and provides customer service and related activities for the U.S. Department of Defense and the U.S. Department of Veterans Affairs and their beneficiaries. Government Health Administrators WPS Government Health Administrators manages Medicare Part A and Part B benefits for more than 7 million beneficiaries. As one of the largest contractors for the Centers for Medicare & Medicare Services, we've served Medicare beneficiaries and their health care providers since 1966. Arise Arise Health Plan provides innovative and high-value health plans to groups and individuals in eastern and northeastern Wisconsin. With our quality Wisconsin-based customer service, Arise offers health care expertise with a personal touch. EPIC Specialty Benefits EPIC Specialty Benefits provides businesses group insurance products that cover: * Life * Disability * Dental * Vision * Voluntary benefits Stay connected: Sign-up for Job Alerts FOLLOW US! Facebook Twitter LinkedIn Wisconsin Physicians Service Insurance Corporation Omaha NE

Prior Authorization Rep

Prime Therapeutics LLC