Job Overview:

The prior authorization specialist is responsible for coordinating all aspects of the prior authorization process, including insurance verification, formulary reviews, gathering necessary clinical information from electronic medical record, and timely communication with patients, prescribers and physician office staff. Candidates should possess knowledge of third party reimbursement regulations and medical terminology as well as seek out assistance from a pharmacist or physician as necessary. Success in this role will require strong communication, interpersonal, and problem solving skills. This person should be able to interact and communicate effectively with internal and external customers, physician office staff, and all members of the organization.
Essential Functions
• Research and investigate Prior Authorization (PA) requirements by insurance company
• Obtain Prior Authorization status updates from the insurance company and communicate to patient, pharmacy, or physician’s office as necessary
• Submit Prior Authorization application forms and all required supporting documentation to the insurance company
• Review medical record to obtain necessary patient demographic and clinical information and seek timely clarification from pharmacist or physician as necessary
• Review Prior Authorization denials and communicate reasons for denial to physicians and patients
• Serve as a subject matter expert for drug formularies and the prior authorization process in general
• Follows up with insurance companies in a timely manner regarding Prior Authorizations
• Provides excellent customer service as evidenced by a willingness and ability to assist customers (both internal and external) with their questions/concerns, treating customers in a friendly and helpful manner, and maintaining a positive attitude

Job Requirements:

High School Degree or GED in Pharmacy; Pharmacy Technician or Medical Assistant
Certified Pharmacy Technician or Certified Medical Assistant desired
Prior experience with medication Epic and/or prior authorizations desirable
2-3 years experience Clinical Pharmacy Pharmacy Technician or Medical Assistant

Job Responsibilities:

Other job-related information:

Working Conditions:

Climbing - Rarely
Concentrating - Frequently
Continous Learning - Consistently
Hearing: Conversation - Consistently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Rarely
Pulling - Rarely
Pushing - Rarely
Reaching - Rarely
Reading - Consistently
Sitting - Consistently
Standing - Occasionally
Stooping - Rarely
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Walking - Rarely

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 

Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service 
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community