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Cleveland Clinic Pharmacy Authorization Rep - Medical Injections in United States

Job ID: 136865

Responsibilities:

  • Cross trained to staff all areas of authorizations supporting any Institute or Facility with minimal leadership guidance.

  • Acts as a resource for training of new team members and during the implementation of new processes.

  • Performs follow up activities for pending status prior authorizations in accordance with standard operating procedures.

  • Obtains medical benefit and or pharmacy benefit authorizations via payer portal, by phone or fax.

  • Retrieves correct clinical information from various sources (i.e. office notes, labs, and other relevant reports) within electronic medical record for submission.

  • Communicates with providers, clinical staff and office staff to obtain clinical information and/or coordinate peer-to-peer conversations.

  • Reviews payer websites for medication changes and updates related to authorization submissions.

  • Communicates with providers and clinical staff to assess medical necessity to support complete authorization submission.

  • Collaborates with Financial Navigators to assist with Patient Assistance program enrollment.

  • Facilitates adherence to Medicare requirements including knowledge of Medicare Local Coverage Determinations (LCDs) and Payer Clinical/Medical Policies.

  • Maintains productivity and quality expectations set forth by department.

  • Other duties as assigned.

Education:

  • High school diploma or equivalent.

Work Experience:

  • Minimum three years previous prior authorizations, precertification experience with medications or other outpatient healthcare setting, or other relevant experience required.

  • Medical Terminology required.

  • Prior experience with third party billing preferred.

  • Prior knowledge of ICD-10, HCPCS and CPT codes preferred.

  • Prior knowledge of healthcare insurance prior authorization preferred.

  • Ability to multitask within multiple accounts in high volume insurance verification processes.

  • Candidate must demonstrate PC skills efficiency in Word, Excel and Outlook.

  • Associate’s degree or diploma/certificate in medical assisting, medical administrative assisting, billing/coding, or other healthcare related field may substitute for up to one year of the required experience.

Physical Requirements:

  • Sufficient mobility and strength to move around the department and throughout the facility.

  • Ability to stand or sit for prolonged periods of time.

  • Excessive walking and standing while obtaining patient information when using laptop computer on wheeled device for bedside registration.

  • Ability to lift 25 pounds.

Personal Protective Equipment:

  • Follows Standard Precautions using personal protective equipment.

Cleveland Clinic is pleased to be an equal employment/affirmative action employer: Women/Minorities/Veterans/Individuals with Disabilities.

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