Under general supervision reviews and completes all medication prior authorizations, tier exception requests, and formulary inquiries for Memorial Medical Group patients. Primarily focusing on outpatient pharmacy requests, partners with Memorial Medical Group to provide a resource for timely outpatient medications that will increase clinical and operational processes which will positively impact patient safety and quality. Follows all applicable regulations, policies, and guidelines to ensure compliant and appropriate management of outpatient medications when insurance intervention is necessary

Embodies the Memorial Health System Performance Excellence Standards of Safety, Quality, Integrity and Stewardship that support our mission, vision, and values:

Responsible for working medication prior authorizations from Memorial Medical Group.

Responsible for obtaining necessary prior authorizations, tier exceptions and information regarding medication dispensing needs for patients in need for medications prescribed by Memorial Medical Group providers.

Maintains documentation accordingly in appropriate EMR. Works directly with pharmacies to provide updated information to ensure dispensing of medications.

Accountable for improving clinical efficiency and effectiveness by ensuring prescriptions meet insurance requirements, allowing the care teams to spend more time with patient care.

Displays ability to understand insurance coverage and how to obtain pre-authorization when necessary.

Provides guidance, based on insurance needs, to Memorial Medical Group providers regarding medication dispensing guidelines based on insurance formularies.

Uploads or documents prior authorization information into the appropriate EMR to ensure all parties are aware of information.

Must operate effectively with various levels of leadership and clinical expertise, while assisting with accomplishing department goals and objectives.

Assists team members with completion of duties in a timely and accurate manner while being able to function independently with assigned duties.

Maintains accurate and timely documentation and follow up when applicable.

Interacts with co-workers, visitors, physicians and other healthcare personnel in a manner that enhances service delivery and promotes positive relationships.

Adheres to all HIPAA guidelines and patient confidentiality policies. Applies the minimum necessary standard when accessing protected health information.

Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.

Education:

High School Graduate or equivalent required.

Experience:

Two years of healthcare experience

Other Knowledge/Skills/Abilities:

Working knowledge of insurance requirements and coverage.
Understanding of insurance prior authorization processes.
Strong general computer skills in Microsoft Office; especially Microsoft Excel spreadsheets, databases, and reporting tools strongly preferred.
Interacts effectively with physicians and/or office staff when receiving information regarding outpatient prior authorization of medications
Possesses strong knowledge of medical terminology.

Utilizes appropriate EMR to document prior authorization processes and outcomes to ensure continuity of care for patients
Effectively communicates with retail pharmacies to ensure medication insurance needs are met
Demonstrates understanding of evidence-based healthcare.
Demonstrates ability to work in a fast changing and ambiguous environment.
Engaging service-oriented skills required.
Excellent organizational skills required. Demonstrates ability to be flexible and function in stressful situations.
Excellent oral, written communications and interpersonal skills required.
Demonstrates initiative, self-direction, and motivation.
Demonstrates open/global communication skills with multiple requesters.
Ability to work with multiple care providers and maintain positive working relationships.

Memorial Health

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Medication Prior Authorization Specialist