Pharmacy Authorization Representative II - BioPlus Specialty Pharmacy
Core
Administer prior authorization requests for patients requiring drug approvals under various health plan therapy types.
Role type
Pharmacy Prior Authorization Specialist
Builds
Expedited drug approvals and appeals for specialty medications
Domain
Healthcare / Specialty Pharmacy / Insurance Payer Operations
Deliverable
client delivery
Required skills
Medicare/Medicaid/Managed Care reimbursement guidelines, medical necessity documentation, insurance denial review, physician office communication, demographic/medical data retrieval
Preferred skills
Specialty pharmacy experience, oncology regimen interpretation, NCCN-guided rationale application, step therapy/site-of-care criteria analysis
Technologies
Prior authorization systems, payer portals
Responsibilities
Review accuracy and completeness of prior authorization requests, assist in completing medical necessity documentation, collaborate with departments to obtain authorizations/appeals, document insurance interactions, review denials and submit appeals, contact physician offices for data
Seniority
Individual Contributor, Non-Management