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Prior Authorization Specialist

Southborough, Massachusetts
Job Type
19 May 2023
Company Overview:

Join us in our mission to transform healthcare! RxAdvance, now doing business as nirvanaHealth, is committed to bringing the art of possible to the payer and PBM industries, which is why we strive to invest in our employees throughout all stages of life. Success radiates through all levels of employees here, with competitive benefits, a strong focus on employee wellness, and optional education courses offered through UDEMY: we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria - the first robotic process automation cloud platform designed for healthcare.

Led by our chairperson John Sculley (former Apple CEO) and noted healthcare entrepreneur and founder of ikaSystems Ravi Ika, nirvanaHealth endeavors to sizably reduce the $900 billion in waste in healthcare administrative and medical costs. We are seeking A-players to join our team - folks who embrace the grind and hustle of a growing company, are collaborative and innovate, are life-long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Prior Authorization Specialist works with Clinical Innovation, Benefits, Implementation, Operations, and Consumer Services teams. The Prior Authorization Specialist is responsible for reviewing prior authorization requirements with a Clinical Innovation Pharmacist and addressing PA questions from members, providers (prescribers), pharmacy personnel, and Health Plans.

Job Responsibilities (but not limited to):

Triage phone calls and written inquiries from members, pharmacy personnel, providers (prescribers) and Health Plans
Provide support for Clinical Programs to create and maintain prior authorization guidelines for clinical product offerings.
Gather all required information for the PA review.
Intake Prior Authorization requests from the phone and fax queue.
Review and approve physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
Interact with the clinical prior authorization team.
Maintain accurate and complete documentation of all inquiries for continuous improvement.
Effectively communicate issues and resolutions to members, pharmacy personnel, providers, and appropriate internal staff.
Research and provide feedback inputs to appropriate teams on insurance benefit details for commercial, exchange, Medicare, and Medicaid payers.
Follow all internal Policies & Procedures to ensure consistency, accuracy, and operational effectiveness.
Support the Fraud, Waste, and Abuse program by reviewing medication utilization records, communicating any suspected fraud discovered, and recommending course of action for providers.
Keep up to date with industry trends and regulatory changes in the pharmacy industry.
Use judgement and problem-solving skills to resolve members', pharmacy personnel's, and providers' concerns.
Attends required training as needed.
Attends required meetings as needed.
Work collaboratively with other teams to resolve issues and improve operational processes.
Work closely with diverse departments to manage daily operations within schedule, scope, and quality to meet established service level agreements.
Other responsibilities as required
May require availability on weekends


Education and/or Training:

High school diploma or the equivalent required
Associate's or bachelor's degree is preferred

Professional Experience:

A minimum of 2 - 5 years of pharmacy technician experience overall in a retail pharmacy, PBM, hospital, clinical pharmacy, or long-term care environment


PTCB or equivalent certification required
Active Pharmacy Technician license (multiple states may be required)

Specialized Skills:

Ability to visualize processes and identify core functions.
Able to work cross-functionally with multiple departments.
Excellent communication, writing, and organizational skills with the ability to multi-task and collaborate in a team.
Self-motivated and detail-oriented with the ability to resolve complex matters.
Ability to handle and remain calm during high stress situations or when pressure is high

Technical Skills:

Strong PC skills; MS Word, Excel, Access, and Power Point.

Additional Considerations:

Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy
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  • Job Reference: 1010175265-2
  • Date Posted: 19 May 2023
  • Recruiter: rxadvance corporation
  • Location: Southborough, Massachusetts
  • Salary: On Application
  • Sector: Healthcare & Medical
  • Job Type: Permanent