Prior Authorization Specialist - Verity Solutions - Remote

Job Description Summary

We are seeking a detailed-oriented and experienced Prior Authorization Representative. The ideal candidate will have a strong background in prior authorization and operational tactics in a healthcare setting, with a focus on maintaining efficient prior authorizations. This role is crucial for managing customer accounts, following medical and pharmacy plan guidelines, all while providing exceptional service to our clients.

Job Objective

This role follows detailed processes specific to obtaining pre-approval for clinical services such as infusion and injection medications provided in a medical practice setting. Additionally, implements and supports specific client prior authorization services defining standardized and best practice workflows and tactics that ensure exceptional patient care.

Duties and Responsibilities:

• Perform medical and pharmacy benefit verification
• Review clinical documentation to ensure patients meet clinical criteria
• Submit prior authorization requests accurately and in a timely manner
• Follow up on prior authorization submissions to obtain written decisions from insurance
• Respond to customer requests in a timely manner
• Attend internal and external meetings
• Supports and promotes Verity Solutions values through positive interactions with both internal and external stakeholders on a regular basis
• Assist with training of new team members
• Attend to other team or cross-departmental initiatives as assigned

Experience, Skills and Qualifications:

• Advanced knowledge of HCPCs, CPT and ICD-10 codes
• High-level understanding of medical insurance, PBM, HCPCS codes, and HIPAA Compliance
• Ability to read and identify clinical documentation
• Knowledge of medical insurance requirements for various medical fields required.
• Experience working in insurance portals such as Availity
• Background in the field of Rheumatology, Allergy and/or Immunology is highly preferred
• Demonstrated ability to self-manage work prioritization between standard daily work activities and attending attend to critical client issues
• Able to prioritize tasks and work in a fast-paced environment
• Demonstrated ability to maintain professional demeanor and confidentiality
• Proven ability to use critical thinking and problem-solving skills to analyze and troubleshoot problems with customers
• Demonstrated interest in customer and colleague success through sharing knowledge, ideas, tips and experiences
• Proven ability to communicate verbally and in written form at a high level
• Ability to multitask and manage multiple discreet patient records at the same time
• Visible enthusiasm for on-going learning
• Role models a passion for working with customers, proactive problem-solving and troubleshooting, and embodying a culture to exceed expectations

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.For this position, we anticipate offering an hourly rate of 21 - 32 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Originally posted on Himalayas

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