Prior Authorization Guidelines Specialist I (CPhT)

Exemption Status:

United States of America (Non-Exempt)

$22.99 - $30.35 - $37.71

“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

Summary

Provide technical and administrative support to the Fee-For-Service (FFS) Medicaid department, primarily by  working  directly  with  the  client  teams,  Clinical  Program  Managers  (CPMs),  Clinical  Specialists,  and Clinical PA Guidelines/Drug Information Management staff to create and support the appropriate administration  of  pharmacy  information  to  include  Medication  Request  Guidelines,  Medication  Request Forms (MRFs), and electronic rules.

Support PA in researching PA-related tasks, PA Implementation and perform Prior Authorization processing as needed.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Create and maintain PA Guidelines documents (content management, file maintenance and archiving, coding and linking in on-line electronic systems).

Provide technical and administrative support to the Clinical Program Manager, Clinical PA Guidelines, Drug  Information  and  PA&UM  staffs  with  the  Medication  Request  process  to  include  formatting, verifying and testing of client Medication Request Guidelines (custom and standard) and formatting/development of Medication Request Forms (MRFs) and electronic rules.

Communicate with clients to obtain client authorization of final documents and ensure timely distribution of documentation to appropriate departments.

Direct the timely and accurate communication of information to appropriate department staff to include: Medical Exception/Prior Authorization; Medication Request Forms (MRFs); Clinical Document Maintenance, electronic prior authorization and formulary management rules, and associated tools and programs.

Manage review/QA process for medical exception/prior authorization guidelines prior to implementation and distribution to clients or internal users.

Serve as subject matter expert on processes related to the procedures necessary to ensure effective maintenance of MedImpact Prior Authorization program, and as a resource for  PA guidelines related questions and/or inquiries from both internal and external customers

• Supervisory Responsibilities
• No supervisory responsibilities
• Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Education and/or Experience
• AA and 2+ years’ experience or equivalent combination of education and experience
• 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.
• Certificates, 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 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. Self-starter with the ability to work independently and as part of a team. 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.
• Reasoning Ability
• Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few 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 and to draw and interpret bar graphs.
• 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:
• Composure
• Decision Quality
• Organizational Agility
• Problem Solving
• Customer Focus
• Drive for Results
• Peer Relations
• Time Management
• Dealing with Ambiguity
• Learning on the Fly
• Political Savvy

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is a full-time 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 or on holidays as required.  This may be changed at any time to meet the needs of the business.  The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel; however, attendance may be required at various local conferences and 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.