Medical Prior Authorization Specialist at Onco360

Waltham, Massachusetts, United States -

Full Time

Start Date

Immediate

Expiry Date

09 Jul, 26

Salary

23.0

Posted On

10 Apr, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Prior authorization, Medical billing, Benefits verification, Insurance authorization, Oncology pharmacy, Infusion therapy, Medicare, Medicaid, Commercial insurance, HIPAA compliance, Clinical documentation, Appeals process, Pharmacy terminology, Analytical skills, Time management, Communication skills

Industry

Pharmaceutical Manufacturing

Description

Onco360 Pharmacy is looking for a Medical Prior Authorization Specialist for our Pharmacy located in Waltham, MA. Work Hours: Monday-Friday - Daytime Hours either 8:30- 5 EST or 9:30-6 EST **Starting salary at $23/hr** We also offer quarterly incentive bonuses. We offer a variety of benefits including: * Medical, Dental & Vision insurance * 401k with a match * Paid Time Off and Paid Holidays * Tuition Reimbursement * Paid Volunteer Day * Floating Holiday * Referral Incentive * Paid Life, and short & long-term disability insurance Medical Prior Authorization Specialist Summary: The Medical Prior Authorization Specialist will ensure patients receive medications that requires pre-authorization from insurance carriers by reviewing orders and clinical documentation received and investigate/identify authorization requirements needed to obtain medication coverage. They will ensure accurate insurance benefit documentation is made for specific IV and infused therapy orders. Medical Prior Authorization Specialist Major Responsibilities: * Manage prior authorization requests and appeals with insurance carriers as well as collaborating with physicians, pharmacists, and other departments. * Develop expertise and maintain in-depth knowledge of insurance authorization policies, coverage terms, and complex authorization and appeal process. Identify the appropriate clinical records and submit the authorization request to the insurance company based on plan requirements for approval. * Maintain accurate documentation of authorization details and proactively monitor and renew expiring authorizations. * Facilitate process for requesting medical authorizations, completing appeals for applicable commercial, Medicaid, and Medicare, or facility medication claims. * Will require reimbursement experience for oncology and/or specialty injected/infused products in a buy and bill setting across all sites of care. * Ensure HIPAA compliance while handling sensitive patient information. * Communicate succinctly and professionally both verbally and through written correspondence with Physician offices, nurses, insurance companies and patients as needed. * Exhibits a positive, courteous, respectful, and helpful attitude towards patients, team members, payers, and management. Contributes team effort by accomplishing related tasks as needed and other duties as assigned. * Knowledge of payer landscape including state, federal, private third-party reimbursement issues, methodologies, and policies for physician administered products * Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. Education/Learning Experience * Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification * Desired: Associate degree or equivalent program from a 2-year program or technical school, Certified Pharmacy Technician (PTCB), Specialty pharmacy experience Work Experience * Required: 1+ years’ Prior Authorization experience * Desired: 3+ years Specialty Pharmacy, Medical, and/or Infusion prior authorization experience Skills/Knowledge * Required: Medicare and Medical insurance and benefit verification, medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, coordination of benefits, Understanding Medicare Parts A, B, C, and D, as well as relevant laws and guidelines, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, basic math and analytical skills, Intermediate typing/keyboarding skills. * Desired: Specialty Pharmacy experience, Medicare Billing Experience, Medical Authorization experience Licenses/Certifications * Required: None * Desired: Registration with Board of Pharmacy as required by state law or Certified Pharmacy Technician (PTCB) Behavior Competencies * Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers. A career with us is more than just a job. It's an opportunity to connect and care for our patients, providers, communities and each other. We attract extraordinary people who have a strong desire to live our mission - to better the lives of those battling cancer and rare diseases. Compassion is more important than numbers. We value teamwork, respect, integrity, and passion. We succeed when you do, and our company and management team work hard to foster an environment that provides you with opportunities for both professional and personal growth.

Responsibilities

The specialist manages prior authorization requests and appeals while collaborating with healthcare providers and insurance carriers. They ensure accurate insurance benefit documentation and maintain compliance with all relevant healthcare regulations.