Prior Authorization Coord

Location: Burlington, MA
Job ID: 170566-1A
Date Posted: Sep 15, 2021
Category: Clinical Support

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Job Description

Welcome To

Welcome to Lahey Hospital & Medical Center, part of Beth Israel Lahey Health. Lahey Hospital & Medical Center is a world-renowned tertiary medical center known for its innovative technology, pioneering medical treatment and leading-edge research. A teaching hospital of Tufts University School of Medicine, the hospital provides quality health care in virtually every specialty and subspecialty, from primary care to cancer diagnosis and treatment to kidney and liver transplantation. It is a national leader in a number of health care areas, including stroke, weight management and lung screenings, among many others. Lahey also helps to advance medicine through research and the education of tomorrow's health care leaders.

About the Job

The Prior Authorization Coordinator is responsible for coordinating comprehensive data elements, insurance verification, and clinical information for prescription pre-authorization management.  Maintains knowledge of third party reimbursement regulations and medical terminology. Provides customer support and resolves problems that may arise as a result of customer inquiries.  Assures continuity of care for patients receiving services through onsite and offsite pharmacies.

 

Essential Duties & Responsibilities including but not limited to:

  1. Contacts insurance companies  to determine eligibility and benefits for requested services
  1. Drafts various correspondence letters and sends to insurers as necessary.
  1. Provides information and answers to patient/caregiver questions and refers to clinician when appropriate or requested.
  1. Follows up with the provider, patient, or  insurance company if there are insurance coverage issues in order to obtain financial resolution
  1. Obtains necessary clinical documentation from the requesting provider to use in the prior-authorization process , meet insurer contractual requirements (where applicable), and to optimize patient outcomes
  1. Identifies insurance treatment requirements and assures the requirements are met for prior authorization approval.
  1. Maintain patient records in a timely and complete manner.
  1. Becomes proficient in the use of ICD-9, ICD-10 and CPT codes
  1. Accurately utilize applicable computer software and equipment for access processing
  1. Receives refill requests and queues up prescription renewals for patients with whom the coordinator has ongoing contact.
  1. Builds strong working relationships with departmental staff.
  1. Participates in the specialty pharmacy and manufacturer sourced inventory “White Bagging” process
  1. Identifies and submits requests for patient copay assistance opportunities through, charitable foundations manufacturer copay assistance programs, or manufacturer patient access foundations
  1. Follows established departmental rules, procedures, policies, quality-improving objectives, environmental, safety and/or infection controlling standards.
  1. Attends departmental meetings and/ or documents review of meeting minutes
  1. Responsible for own professional development including meeting all requirements for continuing education, and keeping abreast of current professional literature, both from a clinical and medication safety perspective.
  1. Actively participates in continuous performance improvement activities of the department, including providing suggestions on how to improve day-to-day operations
  1. Has completed all organizational and departmental competency requirements.
  1. Performs assigned projects in an efficient and timely manner
  1. Performs additional tasks as assigned.

 

 

Organizational Requirements:

Maintain strict adherence to the Lahey Hospital and Medical Center Confidentiality policy.

Incorporate Lahey Hospital and Medical Center Standards of Behavior and Guiding Principles into daily activities

Comply with all Lahey Hospital and Medical Center Policies.

Comply with behavioral expectations of the department and Lahey Hospital and Medical Center.

Maintain courteous and effective interactions with colleagues and patients.

Demonstrate an understanding of the job description, performance expectations, and competency assessment.

Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

Participate in departmental and/or interdepartmental quality improvement activities. 

Participate in and successfully completes Mandatory Education.

Perform all other duties as needed or directed to meet the needs of the department.

 

Minimum Qualifications:

Education:

High School Diploma or GED

 

Licensure, Certification & Registration:

 State of Massachusetts Registered Pharmacy Technician; PTCB Certification for Pharmacy Technicians preferred

 

Experience:

2+ years of clinical experience within a healthcare environment (e.g. hospital, retail, managed care etc.). Specialty Pharmacy experience is preferred.

Experience in prior authorization submission process

 

Skills, Knowledge & Abilities:

Knowledge will include, at minimum, prior-authorization workflows, payer relations, prescription claims adjudication, and general reimbursement procedures. 

Uses excellent customer service, written and oral communication skills. 

Ability to understand and follow specific instructions and procedures;

Superior communication skills

Demonstrated knowledge of insurances, drug formularies and drug products

At least one year of pre-cert experience, including navigating websites for online benefit reviews

Excellent clerical, computer, multi-tasking, resource management and phone skills

Skill in the use of personal computers and related software applications.

Creative thinking and problem solving skills, and ability to work well under pressure (most of the paperwork is time sensitive)

Ability to understand importance of and respect for the confidentiality of all patient information in accordance with applicable standards and regulations.

TEAM PLAYER and willing to be diversified

 

 

Key Relationships:

1

Assistant Director of Pharmacy Specialty Care Services

Direct Report

2

Manager of Outpatient and Specialty Pharmacy

Collaboration

3

Assistant Director of Pharmacy

Ambulatory Care Services

Collaboration

4

Nursing, Medical Assistant, and Secretarial Staff

Collaboration

5

Pharmacy Technicians / PA Coordinators

Collaboration

 

Scope/Impact Statement:

 

 

Work Schedule: Indicate either Yes or No as appropriate.  Hours of work may be subject to change based upon the needs of the business/department.

 

On Call: N/A

Shift Rotation: No

Weekends: No

 

 

 

Scheduled Hours

40 Hours

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.