Under direct supervision of the Prior Authorization Supervisor, incumbent interacts on multiple levels with; pharmacists, medical/clinical staff, fiscal personnel, department managers, access services staff, coding staff and billing assistants. External contacts include multiple third party payers, prescription benefit management companies, governmental peer review organizations, and referring physicians. The relationships are inherent to the success of this position. This position is primarily responsible for receiving prescriptions for all medications provided by Pharmacy Services, for various disease states, addressing and rectifying rejected claims, conducting and completing necessary third party (insurance) prior authorization requests, and verifies prescriptions to other non-Hopkins entities in instances where the prescription is not filled by pharmacy services. The level of responsibility is critical, nature of work is complex. The incumbent must possess enhanced knowledge, be the subject matter expert. Possesses high level payer knowledge, and pharmacy benefit manager knowledge in addition for all relative disease states. The Pharmacy Prior Authorization Specialist works autonomously and proficiently, and provides leadership skills necessary to guide the insurance company to understand the disease state. The Pharmacy Prior Authorization Specialists, reviews and understands the patient specific Epic Medical Chart and determines if third party payer criteria is met via labs, images, notes, and progression of disease in order to support submission to the payer for review. The Pharmacy Prior Authorization Specialists completes and inputs Prior Authorizaiton Referrals at the request of physicians, clinical teams and pharmacies into the Epic Pharmacy Tool Kit. The Pharmacy Prior Authorization Specialist also assists and supports the patient assistance team to ensure patients have access to all medications when needed.

Education:

• High School Diploma or Equivalency

Required Licensure, Certification, etc.:

• Registration with the Maryland Board of Pharmacy is required upon hire.
• PTCB Certification, national certification with the Pharmacy Technician Certification Board preferred

Work Experience:

• One (1) year retail pharmacy technician experience preferred.
• One (1) year in health care related billing and or retail pharmacy required , three (3) years preferred.