Prior Authorization Specialist
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Job Description
Prior Authorization Specialist managing rejected claims and prior authorizations for Polaris Pharmacy Services. Maximizing payer reimbursement and ensuring timely pharmacy billing.
Responsibilities:
- Manage and identify a portfolio of rejected pharmacy claims
- Research, analyze, and resolve rejected claims with Medicare Part D plans, third-party insurance companies, and state Medicaid plans
- Perform edits and reversals to secure claim approvals and maximize payer reimbursement
- Contact providers and facility contacts to obtain additional information
- Monitor and resolve revenue at risk related to payer setup, billing, rebilling, and reversal processes
- Identify, document, communicate, and resolve payer and billing trends and issues as part of a team
- Complete, communicate, and submit prior authorization forms promptly
- Support training needs
- Prepare and maintain processing reports and records
- Follow applicable government regulations, including HIPAA
- Comply with departmental safety, attendance, and dress-code policies
- Conduct responsibilities according to the company Code of Business Conduct and Ethics, policies, Corporate Compliance Agreement, federal and state laws, and professional standards
- Perform other assigned duties as business needs require
Requirements:
- High School diploma or equivalent required
- Minimum of one or more years working as a pharmacy technician in a retail environment preferred; long-term care pharmacy preferred
- Framework LTC and general computer knowledge preferred
- 10-key number entry preferred
- Able to read, write, speak, and understand English
- Able to retain a large amount of information and apply that knowledge to related situations
- Able to work in a fast-paced environment
- Basic computer knowledge skills required
- Basic math and analytical skills
- Experience with alphanumeric data entry
- Proficient in Microsoft Word, Excel, and Outlook required
- Customer service skills
- Results-oriented
- Good organization and attention to detail
- Reliable and able to solve problems
- Able to work various shifts and days
- Adaptability to an ever-changing environment
- May need to work overtime, holidays, and weekends
- May sit or stand seven to ten hours per day
- May lift and/or move up to 30 pounds
- Must follow HIPAA, applicable laws, company policies, and professional standards
Benefits:
- Paid holidays: 6 days annually
- 5 sick days annually
- Up to 10 PTO days annually, with rollover options and milestone bonuses
- Option to cash out up to 10 PTO hours each quarter
- Medical, Dental, and Vision insurance
- 401(k), available for part-time and full-time employees
- Company-paid life insurance
- Short-term and long-term disability insurance
- Tuition reimbursement
- Competitive pay with annual performance reviews and merit-based raises
- Career growth potential
- Annual on-site voluntary flu vaccines
- Employee referral bonus program
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