Exemption Status:
United States of America (Non-Exempt)
$35,373 - $45,099 - $54,827
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.
At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!
Job Description
Position Summary
Works as a member of the Prior Authorization Operations team. Processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments. Uses various business applications (MedAccess, FileNet, RightFax, etc.) to perform analysis, obtain information, and enter prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based upon clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.). Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality. Works under general supervision, relying on instructions, work process guidelines, policies & procedures, and company knowledge/experience to perform the functions of the job. Extent of supervision ranges from close, to moderate, to minimal oversight based upon demonstrated skill and performance levels as defined for the position. This position is part of a three-level career path with progression opportunities described in the Core Processing Career Path/Succession Planning Guidelines.
Essential Functions and Responsibilities include the following. Other duties may be assigned.
- Process and finalize PA requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines. Enter prior authorizations (Pas) into the system and prioritize requests. Check formulary alternatives, review tried and failed medications. Utilize drug references and verify the drug being requested is indicated and approved for the condition. Document all related information regarding the PA approval or non-approval. Respond to requests by faxing status of the PA to the physician or pharmacy
- Conforms to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision making. Partners with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
- Accountable to achieve prior authorization processing productivity and accuracy standards.
- Analyzes, researches, and resolves prior authorization processing issues as appropriate for experience and career path level, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from team subject matter experts (SME) or supervisor; and referring unique or high dollar requests to supervisor according to guidelines.
- Coordinates notifications to members, physicians, and pharmacies as required to obtain missing information, manage pended requests, and communicate prior authorization determinations. Documents prior authorization related information and status. Makes outbound calls to obtain information and answer questions about prior authorization status.
- Collaborates with MCO and Self-Insured client teams to understand PBM clients’ prior authorization processing requirements and expectations. As appropriate for experience and career path level, partners with client teams to complete special prior authorization processing projects and provide accurate, timely, and reliable information to client claim inquiries.
- Collaborates with Contact Center Services in resolving prior authorization inquiries and handling incoming calls during periods of high volume.
- Protects and maintains confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.
- Level II – Process PA requests for complex plans, become a subject matter expert and begin mentoring new PACs, demonstrate flexibility and teamwork in covering all needed shifts.
- Level III – Accountable for QA of others’ work and make recommendations for RTL, coaching and training, handle complex research issues, assist with managing the workload by running/creating reports, provide task instructions and monitoring priorities, act as lead covering all shifts including weekend rotations, attend client meetings and act as a subject matter expert in process improvement and system enhancement activities.
Supervisory Responsibilities
This job has no supervisory responsibilities.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education & Experience:
Associate degree (A.A.) or equivalent from two-year College or technical school; and one (1) year related experience and/or training; or equivalent combination of education and experience; Level I: 1 year of healthcare organization, retail, or mail order pharmacy, or PBM experience preferred. Level II: 3 years of healthcare organization, retail, or mail order pharmacy, or PBM experience required. Level III: 6 years or more of healthcare organization, retail, or mail order pharmacy, or PBM experience required.
Computer Skills
Intermediate knowledge of MS Office/Word, Excel, and Outlook and aptitude for new programs. Experience with Windows based database programs is also required.
Certifications, Licenses, Registrations
Must successfully complete one of the national certification exams OR obtain state licensure (in an U.S. State or Territory). Maintains a current Pharmacy Technician License and/or CPhT certification without restriction.
Other Skills and Abilities
Demonstrates ability to appear for work on time, follow directions from a supervisor, interact well with co-workers, understand and follow work rules and procedures, comply with corporate policies, goals and objectives, accept constructive criticism, establish goals and objectives, and exhibit initiative and commitment.
Understanding of managed pharmacy benefit concepts including formularies, prior authorizations, edits, and claim adjudication. Working knowledge of customer service in a retail/outpatient pharmacy environment. Familiarity with pharmacy software data submission requirements. Self-starter with the ability to work independently and as part of a team that includes clinical pharmacists and other PACs. Attention to detail with a high degree of accuracy. Ability to prioritize and multi-task when presented with multiple duties.
Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Mathematical Skills
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent.
Language Skills
Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Competencies
To perform the job successfully, an individual should demonstrate the following competencies:
Business Knowledge - Demonstrates clear understanding of the nature of the business -- its products and services, goals, market, competitors, and challenges.
Customer and Quality Focus - Actively demonstrates a personal concern for understanding client needs, ensuring the quality of products and services, maintains a high level of customer satisfaction, and contributes to continuous improvement of products and processes.
Responsiveness - Responds promptly, appropriately, and effectively to requests, feedback, and new developments, making sure that all relevant concerns and requirements are understood and addressed.
Problem Solving - Analyzes problems logically to identify root causes, seeks input from a wide range of sources, asks insightful questions and formulates effective solutions.
Communication - Expresses self clearly and effectively in face-to-face interactions, presentations, and written documents, and employs active listening skills to ensure productive interactions.
Time Management - Plans effectively to meet target deadlines, foresees delays and responds proactively, sets realistic timetables, utilizes time efficiently, and completes projects on time.
Interpersonal Effectiveness - Demonstrates good people skills by showing a commitment to teamwork, resolving conflicts effectively and with respect for others’ viewpoints, respecting differences and building strong relationships and networks.
Initiative - Proactively gathers and analyzes information, assesses situations, and identifies challenges and opportunities, sees what needs to be done and takes appropriate action.
Adaptability - Adjusts quickly to evolving situations by integrating new information, remaining flexible, recognizing, and implementing necessary changes and taking advantage of opportunities presented by new developments.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision and ability to adjust focus.
Working Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is in an office setting and is exposed to moderate noise (examples: business office with computers and printers, light traffic).
Working Hours
This is a non-exempt position requiring one to be able to work overtime from time to time in order to get the job done. Therefore, one must have the ability to work nights, weekends and/or on holidays as required. This may be changed at any time to meet the needs of the business. The core business hours for this position are 6:00 AM to 7:00 PM seven days per week. Shifts are scheduled throughout this period based on business needs.
Travel
This position does not require travel, however attendance maybe required at various local training sessions and/or meetings.
The Perks:
- Medical / Dental / Vision / Wellness Programs
- Paid Time Off / Company Paid Holidays
- Incentive Compensation
- 401K with Company match
- Life and Disability Insurance
- Tuition Reimbursement
- Employee Referral Bonus
To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers
MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego,
California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.
Equal Opportunity Employer, Male/Female/Disabilities/Veterans
OSHA/ADA:
To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Disclaimer:
The above
statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
