Job Description

Position Summary:
The Prior Authorization Specialist handles all prior authorizations, third party appeals, and pending third party payer issues across all Equitas Health medical centers. This individual will work with internal and external pharmacies, CoverMyMeds, the EHR, and all Equitas Health health center providers to facilitate prior authorization completion. This individual must be able to work in conjunction with the pharmacy department and health center staff to facilitate the prior authorization process.


Essential Job Functions:
The Prior Authorization Specialist is responsible for handling all prior authorizations, appeals, and third party medication disputes for providers at Equitas Health. The Prior Authorization Specialist will be required to communicate with prescribers, pend medication changes, and maintain exceptional documentation in the patient health record. The staff member will also be in constant communication with internal pharmacies, external pharmacies, and patients waiting on prior authorizations. Essential job functions include, but are not limited to, driving or having reliable transportation, written and verbal communication, utilizing a computer for typing, multi-system use/maintenance, and attending meetings.

 
Major Areas of Responsibilities:  

• Complete prior authorizations submission within established time frame. 
• Collaborate with providers to manage appeals and/or peer-to-peer discussion with third party representatives. 
• Ensure proper documentation is maintained in the EHR. 
• Work with clinical pharmacist team to provide potential therapeutic substitutions to prescribers 
• Communicate with the clinical team on the status of prior authorizations or changes that must be made for therapy to continue for the patient. 
• Maintain constant communication with the internal and external pharmacy teams for medication processing. 
• Inform patients when prior authorizations are approved. 
• Provide data on prior authorizations as needed to Senior Leadership. 
• Other duties as assigned by the Prior Authorization Supervisor, Director of Nursing, and Leadership. 
• Comply with the Equitas Health Care Corporate Compliance Standards of Conduct and related policies and procedures. 
• Demonstrate unconditional positive regard to clients and conduct all aspects of job responsibilities. 
• Continuously grow and develop cultural competency, exhibiting an understanding, awareness, and respect for diversity.
• Contribute to a positive work environment by demonstrating unconditional positive regard to all Equitas Health employees, interns, etc. with an understanding, awareness, and respect for diversity. 

 
Education/licensure:  

• Medical Assistant, Certified Pharmacy Technician or Registered Pharmacy Technician (must be registered with State of Ohio Board of Pharmacy). 

 
Knowledge, Skills, Abilities and Other Qualifications : 

• Experience working in medical records preferred. 
• Must be able to accurately and effectively meet established deadlines 
• Experience with prior authorizations preferred. 
• Strong attention to detail. 
• Ability to be flexible in working hours. 
• Must ensure detailed and thorough documentation. 
• Exemplary written and verbal communication skills. 
• Knowledge of healthcare terminology. 
• Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, sexual practices, chemical dependency and a demonstrated competence in working with persons of color, and gay/lesbian/bisexual/transgender community.
• Proficiency in all Microsoft Office applications, computers, email, web-based systems and electronic health records.
• Reliable transportation, driver’s license and proof of auto insurance required. 

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