Careers
Woods Hole, Massachusetts
New York, NY
Posted: 08-Sep-23
Type: Full-time
Salary: Open
Internal Number: R88547
Scope of Position
The Ohio State University Wexner Medical Center is committed to improving access and service to customers. The Prior Authorization Coordinator (PAC) functions as an integral member of the health care team to reflect a culture of cooperation, enthusiasm and mutual respect. This position ensures the coordination of the insurance verification and prior authorization process for outpatient medications. This process includes, but is not limited to, assisting in defining pharmacy co-pay information, benefit design, and coverage. This information is important to both patient and physician planning as well as ensures the appropriate information is available and used for successful billing.
Position Summary
The PACs responsibilities include understanding and verifying benefits, obtaining prior authorization for outpatient medications, collecting and interpreting patient clinical information. In addition, the PAC may be required during the authorization process to contact patients/families in order to gather information while also informing patients of medication co-pays or co-insurances. Communication will also be necessary with physicians, payers, and other customer groups. PACs must be able to navigate the electronic medical record system to obtain and interpret pertinent medical information for the prior authorization process, including the determination of whether a medication is being used within or outside FDA labeling, relevant lab results, genetic testing and pathology. PACs will solve routine customer problems.
Duties and Responsibilities
65% of time: Prior Authorization
- Demonstrates proficiency in operating within the Integrated Healthcare Information System (IHIS) and Willow Ambulatory (WAM) as needed to facilitate prior authorizations.
- Accurately identifies the patient through an inquiry function of the pharmacy system or via provider referral.
- Performs insurance verification process for outpatient medications.
- Works with team and accesses Electronic Medical Record to obtain necessary clinical and financial information for medication prior authorization.
- Determines whether use of the medication is within or outside FDA labeling.
- Coordinates communication with team to clarify information required.
- Gathers clinical evidence from primary literature or guidelines to submit with prior authorization process that supports the appropriateness of the selected medication.
- Demonstrates knowledge and understanding of clinical parameters required for prior authorization process.
- Prepares appeals of medication denials, managing the process in an efficient manner and performing regular follow-up to ensure timeliness of appeals redetermination.
- Coordination of benefits with external pharmacy partners if required by patient insurance.
- Triages medication assistance referral to Medication Assistance Program Coordinators in the instances of unsuccessful appeals and if patients have been rendered uninsured by an insurance denial.
- Works collaboratively with the Financial Counselors and Medication Assistance Program Coordinators on a routine basis including when insurance has terminated or a co-insurance or co-payment is unaffordable and the patient may be in need of financial assistance.
- Demonstrates thorough knowledge of payor-specific preferred agents, requirements, and processes which might impact approach to payer efforts.
- Demonstrates knowledge of appropriate channels for prior authorization based upon payor.
- Utilizes the most efficient technology and resources available, including eligibility systems.
- Enters all insurance data into pharmacy system appropriately and accurately and in a timely fashion.
- Uses complex problem-solving skills when relying on other departments to complete needed clinical information submission to payers.
- Scans documents and insurance cards into the hospital imaging system.
- Follows escalation processes on all unusual procedures, insurances, or circumstances.
25% of time: Customer Service
- Informs patient or physician of requirements necessary prior to service.
- Demonstrates excellent team behaviors.
- Serves as liaison between insurance companies, physicians, specialists, patients and other OSUMC hospital personnel.
- Responds to patient questions in a way conducive to patient satisfaction.
- Phones patients to obtain additional demographic and insurance information and enters this information into pharmacy system.
- Resolves routine customer service issues in a timely manner and to the satisfaction of physicians, patients, and payers.
- Educates and provides feedback to pharmacists, pharmacy technicians, and other pharmacy staff as needed to improve departmental knowledge of prior authorization processes and workflows.
10% of time: Productivity, Quality Management and System Maintenance
- Orients new staff to the department or area.
- Precepts new staff as needed.
- Works competently in designated systems to ensure accuracy, thoroughness and efficiency.
- Works collaboratively with others within and outside the department of pharmacy on quality improvement initiatives and projects related to the departments strategic plan.
- Maintains all departmental standards including productivity tracking, Quality Assurance monitoring, and time off.
- Advocacy
- Team meetings
- All other duties as assigned.
Organizational Expectations:
Employees will practice within the Medical Centers polices and procedures. PACs will adhere to the Intensive Caring Value Statements as demonstrated through positive patient/guest relations, positive and effective interaction with staff and formulating and meeting departmental goals. There must be commitment to following through on all payer issues to support the patient, the physician, and the health system. A high value is placed on dependability, flexibility, productivity, and reliability.
Minimum Qualifications
For Hire: Registered Nurse (RN) preferred. Experience in interpreting insurance benefit information and completing prior authorization process is preferred. Knowledge of medical terminology is preferred. Experience with internet and internet navigational tools is desired. Excellent interpersonal skills are desired, especially the ability to communicate and work effectively with a team. Employee must be highly organized, detail oriented, and able to manage multiple projects at a time. Some professional licensure or certification is required for employment.
- Bachelors degree or equivalent experience in nursing, or health care-related field and 1 year experience in health care setting, or physicians practice, or bachelors degree in any field with 3 years experience in clinical health care setting or physicians practice required.
- Registered Nurse (RN) with active license preferred
- If applicant is a social worker:
- 1 year experience in health care setting, or physicians practice required.
- Must have active license.
- Must be registered in the state of Ohio as a certified pharmacy technician, registered pharmacy technician, or eligible for registration as a pharmacy technician trainee. If applicant does not already meet above requirements, must complete registration as a pharmacy technician trainee within 15 days of hire.
- Must achieve registration as a certified pharmacy technician within 180 days of hire. If current PTCB certificate is in place upon hire, but not already registered, must complete registration as a pharmacy technician trainee within 15 days, and achieve registration as a certified pharmacy technician within 60 days of start date.
- If applicant is a pharmacy technician:
- Must complete Pharmacy Technician Certification Board (PTCB) certification within 180 days of hire, unless current PTCB certificate is in place upon hire.
- Must be registered in the state of Ohio as a certified pharmacy technician, registered pharmacy technician, or eligible for registration as a pharmacy technician trainee.
- If applicant does not already meet above requirements, must complete registration as a pharmacy technician trainee within 15 days of hire.
- Must achieve registration as a certified pharmacy technician within 180 days of hire. If current PTCB certificate is in place upon hire, but not already registered, must complete registration as a pharmacy technician trainee within 15 days, and achieve registration as a certified pharmacy technician within 60 days of start date.
Ongoing:
- If RN, nursing license in the state of Ohio must be maintained and active
- If social worker, license in the state of Ohio must be maintained and active
- If pharmacy technician, PTCB certification and Ohio Board of Pharmacy registration must be maintained and active.
- Demonstrates competence in daily functions, interpersonal and cognitive skills required to meet essential job functions.
- Remains current with all departmental computer software.
- Attends medical center and departmental in-services, educational forums and meetings as required.
Patient Population Served
Knowledge of growth and development and an understanding of the range of treatments necessary to meet the age specific needs of the patient population served (Check those that apply):
Not Applicable: Non-patient care title
Adolescents (14 - 17 years)
X
Neonates (0 - 6 months)
X
Adults (18 - 64 years)
X
Children (7 months - 13 years)
X
Geriatrics (65 + years)
X
Job Relationships
Supervisory Responsibility: N/A
Contacts: Patients and their employers, physicians, Hospital personnel, insurance companies, and governmental agencies.
Responsible to: Manager, Insurance Verification
Physical/Visual/Mental Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee must be able to:
- Concentrate and pay attention for periods of time up to 8 hours to perform such tasks as verifying and billing.
- Communicate clearly with third-party payers, patients, and hospital personnel.
- Move objects weighing up to 30 pounds or less, have ability to reach by extending hands and arms, and handle objects by grasping or holding.
- Function at a computer workstation.
- Have finger dexterity (writing, operating a keyboard and push-button phone).
- Sit in a normal, seated position for extended periods of time.
- Speak English clearly, produce a clear telephone voice.
- Understand the voice communication while talking on the phone and to hear technical sounds.
- Have near vision of objects within two feet, ability to distinguish colors and visual and mental concentration for extended periods of time.
- Walk frequently about the work area and medical center on foot.
- Perform necessary duties and maintain safety within the department.
Work Environment
This job involves everyday risks or discomforts which require normal safety precautions, use of safe work practices with office equipment, avoidance of trips and falls, and observance of fire and other safety regulations.
Note: The above statements are intended to describe the essential functions and related requirements of persons assigned to this job. They are not intended as an exhaustive list of all job duties, responsibilities and requirements.
