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Specialty Pharmacy Prior Authorization Specialist Medical Authorizations
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Full-time
high school, professional certificate
Posted 33d ago
~40 hrs/week
Responsibilities
Responsible for the precertification of eligible prescription medications by ensuring documentation meets insurer guidelines for medical necessity. Acts as a primary liaison between physicians and insurance companies to facilitate reimbursement and proper charge capture.
Requirements
Requires a High School Diploma and 3-5 years of pharmacy experience. Must hold a Tennessee Pharmacy Technician license and PTCB certification.
Full job description
If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!
We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.
Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.
A Brief Overview Responsible for precertification of eligible prescriptions. Ensures complete documentation is obtained that meets insurer guidelines for medical necessity and payment for services. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
What you will do
Responsible for precertification of eligible prescription medications for inpatient and outpatient services based on medical plan documents and medical necessity. Ensures medical documentation is sufficient to meet insurer guidelines for medical necessity documentation and procedure payment.
Reviews clinical information submitted by medical providers to evaluate the necessity, appropriateness and efficiency of the use of prescription medications.
Assists with patient assistance and grant coordination for Patients for outpatient pharmacies from designated areas.
Proactively analyzes information submitted by providers to make timely medical necessity review determinations based on appropriate criteria and standards guidelines. Verifies physician orders are accurate. Determines CPT, HCPCS and ICD-10 codes for proper Prior Authorization.
Contacts insurance companies and third party administrators to gather information and organize work-flow based on the requested procedure.
Collects, reads and interprets medical documentation to determine if the appropriate clinical information has been provided for insurance reimbursement and proper charge capture.
Serves as primary contact with physicians/physician offices to collect clinical documentation consistent with insurer reimbursement guidelines. Establishes and maintains rapport with providers as well as ongoing education of providers concerning protocols for pre-certification.
Communicates information and acts as a resource to Patient Access, Case Management, and others in regard to contract guidelines and pre-certification requirements.
Performs research regarding denials or problematic accounts as necessary. Works to identify trends and root cause of issues and recommend resolutions for future processes.
Education/Formal Training Requirements
Required - High School Diploma or Equivalent
Work Experience Requirements
Required - Pharmacy (clinical, hospital, outpatient, or specialty) 3-5 years
Basic understanding of prescription processing flow. Expertise in utiliizing EMRs to document clinical critieria required for third party approval.
Knowledgeable of medical terminology, drug nomenclature, symbols and abbreviations associated with pharmacy practice.
Strong attention to detail and critical thinking skills.
Ability to speak and communicate effectively with patients, associates, and other health professionals.
Ability to diagnose a situation and make recommendations on how to resolve problems.
Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft Word software.
Excellent verbal and written communication skills.
Supervision Provided by this Position
There are no lead or supervisory responsibilities assigned to this position.
Physical Demands
The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
Must have good balance and coordination.
The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.
Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity.
Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community.
For over a century, Methodist Le Bonheur Healthcare has enhanced the health of individuals in Memphis and the Mid-South.
Industry
Hospitals and Health Care
Company size
10,001+ employees
Founded
1918
Headquarters
Memphis, TN
LinkedIn followers
38,733
Total funding
$1M
Methodist Le Bonheur Healthcare and its dedicated staff of medical professionals are committed to being a leading provider of exceptional, cost-effective patient and family-centered care. In order to benefit the communities we have proudly served since 1918, our vast range of best-in-class services continue to be offered in a manner which aligns with and supports the health ministries and Social Principles of The United Methodist Church.
Offices: 1211 Union Ave, Memphis, TN 38104, US · 1300 Wesley Drive, Memphis, TN 38116, US · 7691 Poplar Avenue, Germantown, TN 38138, US · 50 N. Dunlap Street, Memphis, TN 38103, US
Based on 1145 listings with disclosed salaries, most healthcare jobs in Tennessee pay between $62k–$150k per year. Individual offers vary with seniority, company size, and specialization.
How many Healthcare jobs are open in Tennessee right now?
There are currently 12,994 open healthcare positions in Tennessee listed on Clera. New openings are added daily as companies post roles.
Which companies are hiring for Healthcare roles in Tennessee?
Companies currently hiring include Covenant Health, Vanderbilt University Medical Center, Ascension, Erlanger, Baptist Memorial Health Care, among others. Browse the listings above to see every active employer.
Are there remote or hybrid Healthcare jobs in Tennessee?
Yes — 1301 of the 12994 open healthcare positions offer remote or hybrid work (715 remote, 586 hybrid).
How do I apply for Healthcare jobs in Tennessee?
Each listing links directly to the employer's application page. Apply early — fresh listings get the most recruiter attention in the first two weeks.