Healthcare Services Coordinator - Aspire Health Plan
Welcome to Montage Health’s application process!
PHARMACY TECHNICIAN LICENSE PREFERRED
The Healthcare Services Coordinator will perform duties reviewing coverage for medications under the Medical benefits for all lines of business necessary. The Healthcare Services Coordinator utilizes established company guidelines to review requests from physicians, medical groups, pharmacies, and members for the utilization of prescription drugs and pharmacy benefits. The coordinator conducts research and resolves any inquiries, problems, or issues.
The Healthcare Services Coordinator and is responsible for supervising and directing the support services needed for all Health Services lines of business operations. The Healthcare Services Coordinator will continuously look for ways to improve processes. Contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner.
Prior Authorization for Medical and Pharmacy (Medicare Part B)
- Tracks and triages coverage determination and/or prior authorization requests submitted from providers and determines if a pharmacist review is required.
- Obtains authorizations and requests detailed clinical information from prescribers.
- Approves coverage determination and/or prior authorization requests based on defined criteria.
- Enters and documents coverage determination and/or prior authorization request decisions into the PBM system and notifies providers and/or members.
- Responds to client inquiries regarding authorization approvals and PBM online applications.
- Refers coverage determination requests for specialty drugs to a delegated vendor or client for processing when applicable.
- Contacts providers for additional information to facilitate coverage determination reviews.
- Notifies physicians, providers, and members of coverage determination request decisions.
- Assist pharmacist in training team on pharmacy prior authorization requests and continue to participate in cross-training and process improvement of medical PA requests.
- Oversight and preparation of correspondence, proposals, reports, spreadsheets and forms.
- Assist in maintaining policies & procedures, including editing, proofreading.
- Provide project management assistance as required.
- Answer inbound member and provider calls and assist with authorization and benefit inquiries.
- Coordination and completion of intake/processing for pharmacy and medical authorization and appeal requests. Perform preliminary review for completeness and appropriate documentation. Triage and escalate to the appropriate clinical resource when needed.
- Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/ consultation by a clinician.
- Assist with high-cost case updates.
- Claims resolution management. Coordinate retroactive review process with claims staff and clinical team.
- Coordination of patient specific contracts.
- Provide administrative support to UM Director or Pharmacy Director for Committees chaired by Chief Medical Officer.
- Assist with pharmacy issues in coordination with pharmacy staff.
- Develop excellent professional relationships with our provider and insurance company partners.
- Demonstrate understanding and accurate interpretation to support compliance with regulatory standards, e.g. Medicare Advantage and HIPAA.
- Prioritize and plan work for completion in a timely manner, coordinating with others as needed and meeting deadlines set on all phases of work.
- Maintain a high level of professionalism, safeguarding and preserving the confidentiality of all information in accordance with HIPAA regulations.
- Demonstrate the ability to adapt to changes in the workload and responsibilities.
- Perform other activities and functions as required and ability to evolve with business needs.
- Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.
- Integrity: Consistently honors commitments and takes responsibility for actions and words.
- Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
- Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.
- At least two years of experience in a Managed Care (MCO) in prior authorization for drugs, particularly Medicare Part B.
- Attention to details in obtaining complete and accurate information
- Ability to key data accurately and rapidly
- Ability to communicate effectively, including written and verbal communication skills. Business English and/or technical vocabulary related to health care industry (insurance/medical terminology).
- Basic knowledge of insurance terminology and medical coding, e.g. ICD and CPT
- Ability to operate computer equipment and software programs necessary to fulfill position responsibilities. Efficient use of general office equipment required.
- Working knowledge of Excel and Access, or similar programs and databases.
- Ability to interact professionally with co-workers, providers, clients, brokers and management-level staff.
- Excellent phone manner and ability to handle multiple phone lines.
- Ability to answer questions independently.
- Must be able to problem solve.
- Must be able to meet established deadlines
Minimum A.A. degree
- License/Certification: Valid Pharmacy Technician License preferred; or a BA or BS degree or equivalent with emphasis in Business Administration.
$22-$25 per hour
Equal opportunity employer.
Assigned Work Hours:
M-F, 8 a.m.-5 p.m.
Job Status: Full Time
Job Reference #: 2023-1568