Pharmacy Authorization Representative II - BioPlus Specialty Pharmacy
Core
Administer prior authorization requests for patients requiring specialty medications, ensuring documentation meets payer standards and expediting approvals.
Role type
Pharmacy Prior Authorization Specialist
Builds
Prior authorization approvals and appeals for specialty drug therapies
Domain
Healthcare / Specialty Pharmacy / Insurance Payer Operations
Deliverable
client delivery
Required skills
Pharmacy prior authorization processing, Medicare/Medicaid/Managed Care reimbursement guidelines, medical necessity documentation, insurance denial review, physician office communication, demographic and medical data collection
Preferred skills
Specialty pharmacy experience, oncology regimen interpretation, NCCN-guided rationale application, step therapy criteria analysis
Technologies
Payer systems, clinical documentation tools
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, 2+ years experience