Prior Authorization Spec

Support BCBSM/BCN providers (pharmacists and physicians) with Commercial pharmacy/medical drug benefits analysis, drug coverage inquiries, and prior authorizations.

• Answer telephones in an efficient and timely manner to lend appropriate assistance to providers.
• Triage prior authorization requests under the supervision of a clinical pharmacist.
• Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/medical claims.
• Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.
• Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
• Assist with internal control systems and regulations compliance.

QUALIFICATIONS

• High School Graduate or GED equivalent required. Two (2) years of college preferred.
• Two (2) years of experience in retail or hospital pharmacy required.
• Pharmacy Technician Certification (PTCB) preferred.
• Knowledge of prescription drug names, therapeutic classes, and claims processing.
• Expert knowledge of pharmacy claims processing.
• Understanding of formularies and utilization management edits.
• Computer Literate (Microsoft Office Products).