RX Prior Authorization Coord I
$44,304–$49,837 year
On-sitePortland, Oregon, United States
Job Summary
Process pharmacy prior authorizations using the electronic PA platform by assessing requests against clinical criteria and plan benefits to ensure accurate data entry into the claims adjudication system. Interpret formulary coverage, screen requests for status limits, and triage complex cases to the clinical team while maintaining strict adherence to NCQA turn-around time deadlines. Communicate PA decisions and gather necessary information from providers via electronic interfaces, fax, and telephone to resolve pharmacy conflicts professionally. Support member appeals and grievances by maintaining documentation within required timelines while multitasking in a fast-paced environment. Work flexible hours including evenings and weekends to meet business needs.
Required Qualifications
- High School diploma or equivalent
- Minimum one year working experience in a prior authorization or technician role in a pharmacy or health plan
- State Pharmacy Technician license
- Demonstrated critical decision making
- Ability to interpret benefit contracts, clinical criteria and Moda Health administrative policies
- Demonstrated working knowledge of medical and pharmaceutical terminology
- Computer skills including Microsoft Office products (proficiency with Word and Excel)
- Ability to gain proficiency in Moda internal systems, electronic PA platform and PBM claims processing systems
- Typing proficiency of 40 wpm on a computer keyboard
- Willingness to work hours necessary to successfully accomplish assigned tasks
- Ability to anticipate needs and multi-task
- Consistently meet quality and production standards
- Maintain a high level of confidentiality
- Project a professional business image
- Be flexible and adapt to change
- Handle stress and pressure
- Sound analytical problem solving
- Decision making
- Memory retention
- Organizational skills
- Excellent verbal, written, and interpersonal communication skills
- Active listening
- Teamwork
- Working respectfully with co-workers and members
- Must have the to resolve pharmacy conflicts in a professional manner
- Ability to come to work on time and daily
- Must be able to navigate multiple computer screens
- A reliable, high-speed, hard-wired internet connection
- Must be comfortable being on camera for virtual training and meetings
- Work in excess of standard workweek, including evenings and occasional weekends
Desired Qualifications
- College degree
- Equivalent work experience in health care administration, pharmacy, or other health related fields may substitute for the education requirement
- CPhT
- Preference for fast-paced, production-oriented environment
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