Specialist III, Prior Authorization

Company

Work Schedule Description (e.g. M-F 8am to 5pm)

Remote Work Notification

Hiring Manager : Full Name: First Last

Overview

Navitus Health Solutions is seeking a Specialist III, Prior Authorization to join our team!

The Specialist III, Prior Authorization (PASIII) will function as a subject matter expert (SME), first point of escalation for all issues, and lead contact between PASIIIs, Prior Authorization team, and other Navitus departments. The PASIII will act as a liaison and guide/mentor for Prior Authorization Specialists and Leadership and will assist with resolution of short-term and long-term service issues. The PASIII will perform high-level Prior Authorization functions and tasks as needed while participating in daily production workload when needed. 

The Specialist III, Prior Authorization will be proficient in reviewing, processing, and troubleshooting incoming Prior Authorization requests in both Prior Authorization systems. The PASIII will provide oversight on all Medicare D requests. Additional responsibilities include participation in new associate training, assisting with implementation of regulatory changes, quality monitoring, researching privacy incidents, assisting in audits, and assisting with maintenance of the Prior Authorization Compass site and department policies and procedures. The PASIII will work with other Navitus departments, vendors, and clients as necessary to resolve issues affecting Prior Authorization. The PASIII will coordinate timely and effective communications to and from the PASIIIs to Leadership. The PASIII will be called upon to represent the Prior Authorization department in interdepartmental meetings and projects. 

Is this you? Find out more below!  

Responsibilities

How do I make an impact on my team?   

• Abide by all departmental policies and procedures. Demonstrate appropriate workload management, attitude, and performance. Act as a model for Prior Authorization staff.  

• Function as subject matter expert (SME) by actively managing and resolving issues timely.  

• Provide education, direction, and guidance to staff on managing inquiries. Coach staff through resolution and/or further escalating issues to Leadership as appropriate.  

• Identify barriers to productivity and create action plans to improve efficiencies and productivity. Investigate trends, identify root problems, and work to remove barriers.  

• Participate in quality initiatives, including performance monitoring and auditing. Identify process improvements, educational opportunities, and implement change.   

• Provide department-specific training for associates; Develop/ maintain department-specific training documents and workflows. 

• Assist with maintenance and integrity of the Prior Authorization written policies to ensure they are accurate, comprehensive, and clear.  

• Participate in the maintenance of the Prior Authorization Compass sites. 

• Assist with prior authorization system support to include release testing and training/ support documentation. 

• Consistently meet/exceed performance standards. 

• Act as SME and first point of escalation for questions/issues. 

• Develop and maintain expert knowledge of Medicare D, Medicaid, and/or Exchange programs. 

• Monitor and manage volume; ensure workload is prioritized appropriately. 

• Document and communicate processes and changes to those processes. 

• Assist with preparation/validation of reports. 

• Maintain a flexible schedule that accommodates needs of Prior Authorization. Because position functions as a PASIII, full-time hours are required. 

• Ensure a professional business environment is maintained at all times by Prior Authorization staff. 

• Represent Prior Authorization in interdepartmental meetings and participate in implementation activities for new initiatives and enhancements. 

• Other duties as assigned. 

Qualifications

What our team expects from you?  

• High school degree or GED required. Post-high school education desired such as L.P.N., Certified Pharmacy Technician, Medical Terminology, or Medical Transcriptionist.
• 1 year of experience in Navitus Prior Authorization and high-level knowledge of Prior Authorization processes required.
• Passing audit scores within the past 6 months required.
• Previous customer service experience required.   
• Experience in health insurance/pharmacy insurance or managed care organization preferred. 
• Experience in a PBM or managed care call center desired. 
• Experience in a mail or retail pharmacy setting desired.
• Experience with Medicare and/or Medicaid regulatory guidance desired.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees. 

Pay Range