Pharmacy Prior Authorization Coordinator

Portland - Oregon (OR), 97204

Moda Health

Job Description:

Let’s do great things, together

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

Moda Health is currently seeking a Pharmacy Prior Authorization Coordinator to join our Pharmacy Department. The position will be responsible for processing pharmacy related prior-authorizations for approval or denial, including entering data into appropriate internal and external systems

Primary Functions:

  • Accountable for accurately entering prior authorizations into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members according to corporate policy and government regulations.
  • Responsible for the first pass assessment and evaluation of the prior authorization request prior to higher level review: prepare, assess, evaluate, and make initial determination on the PA request with the information received using established criteria.
  • Interpret formulary coverage and solve pharmacy plan benefit issues for members of multiple commercial, Medicare, and Medicaid plans. Must be able to accurately distinguish member benefit plans and determine member eligibility.
  • Screen requests for formulary status (e.g., PA required, nonformulary excluded, quantity limits, etc.).
  • Monitor pharmacy turn-around time deadlines, track requests on log and/or pend report and take action to ensure required timelines are met.
  • Fax communication forms, more information required forms (MIRF’s), and review criteria to providers.
  • Determine whether additional information is needed from the requesting provider’s office, complete necessary documentation, and inform provider offices.
  • Communicate prior authorization decisions and ensure appropriate feedback and follow-up with all prior authorization requests via fax, telephone, and/or email to requesting providers, members, pharmacies, and internal departments.
  • Provide, schedule and run pharmacy reports as necessary to comply with departmental
requirements from the direct reporting system provided by the PBM vendor.
  • Support, track, maintain, and ensure data and documentation for member appeals, grievances, and complaints are provided within necessary timelines.
  • Interact with providers and provider offices via fax and/or telephone to gather complete, accurate information in order to adequately process a prior authorization.
  • Be an active team player, responding to the needs of the unit as they arise.
  • Perform other duties as assigned.

  • Are you ready to be a betterist?

    If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.

    Together, we can be more. We can be better.

    Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.

    1. Licensed and Certified with Oregon State Board of Pharmacy. 2. One to two years working experience in a pharmacy or health plan in Pharmacy Services department in prior authorization role. 3. Demonstrated working knowledge of medical and pharmaceutical terminology, and computer skills including Microsoft Office products (proficiency with Word and Excel). Must be able and willing to learn a third-party real-time interactive PBM database, where great attention to detail is imperative. 4. Typing proficiency of 40 wpm on a computer keyboard. 5. Willingness to work hours necessary to successfully accomplish assigned tasks. 6. Ability to anticipate needs; consistently meet quality and production standards; maintain a high level of confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure; and, multi-task. 7. Good analytical, problem solving, decision making, memory retention, and organizational skills. 8. Excellent verbal, written and interpersonal communication skills including management of the angry physician or health care provider. 9. Preference for fast-paced, production-oriented environment. 10. Must have ability to work well with Commercial, Medicare and Medicaid populations and to resolve pharmacy conflicts in a professional manner. 11. Ability to come to work on time and on a daily basis.

    Similar Jobs in Oregon