Prior Authorization Specialist - Medication, Rheumatology/Infusion, Downtown Nashville

Job Summary

The Prior Authorization Specialist - Medication is responsible for managing the process of obtaining prior authorizations for medications prescribed by healthcare providers within the department. This role involves collaborating with pharmacies, insurance companies,
and medical staff to ensure timely approval and access to necessary medications for patients. The specialist will handle all aspects of the prior authorization process, including submission, tracking, and appeals, while ensuring compliance with insurance guidelines and departmental protocols.

Responsibilities (include, but are not limited to)

• Receive and review medication orders and obtain necessary prior authorizations from insurance companies to ensure that prescribed medications are covered.
• Act as the primary point of contact between pharmacies, insurance companies, and the healthcare provider’s office to facilitate the approval process.
• Accurately document and track all prior authorization requests, including follow-ups, denials, approvals, and any additional information required.
• Work closely with providers to clarify medication-related questions and assist in providing additional clinical documentation or appealing denied authorizations.
• Communicate with patients regarding the status of their medication authorizations and provide updates or alternate medication option if necessary.
• Assist in preparing and submitting appeals for denied authorizations, ensuring that all required clinical and medical information is provided.
• Ensure all processes are compliant with current regulations, insurance guidelines, and departmental protocols.
• Stay updated on industry best practices, insurance policies, and medication-related changes that may impact the prior authorization process.
• Performs other duties as required/directed.
• This list is not all-inclusive, and any other task or job may be assigned in the future.

Knowledge, Skills, and Abilities

• Pharmacy technician certification or Medical Assistant with experience in prior authorization processes.
• Minimum 2-3 years of experience in a medical office or clinic setting managing prior authorizations for prescription medications.
• In-Depth knowledge of insurance guidelines, medication formularies, and the prior authorization process.
• Strong communication skills, excellent attention to detail, and the ability to work independently and as part of a team.
• Familiarity with electronic health records and pharmacy management software is preferred.
• Maintains reliable and consistent attendance.
• Demonstrated ability to follow and adhere to Heritage Medical Associates’ policies, vision, mission, and values.

SUPERVISORY RESPONSIBILITES

• This job has no supervisory responsibilities

Physical Demands and Work Environment

• Sedentary work, must be able to sit for 8 to 10 hours a day
• Must be able to push/pull up to 25 lbs.
• Ability to delineate between numeric numbers
• Repetitive motion, substantial movements (motions) of the wrists, hands, and/or fingers. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading
• Office environment-limited exposure to communicable diseases
• No exposure to blood-borne pathogens or contaminated body fluids