Prior authorization representative job description
Updated March 14, 2024
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Example prior authorization representative requirements on a job description
Prior authorization representative requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in prior authorization representative job postings.
Sample prior authorization representative requirements
- Bachelor's Degree in healthcare related field
- 2+ years of prior authorization experience
- Proficient knowledge of medical terminology
- Experience working with documentation systems
- Excellent computer skills
Sample required prior authorization representative soft skills
- Strong customer service orientation
- Ability to multi-task and prioritize
- Excellent communication and interpersonal skills
- Ability to work independently and in a team environment
Prior authorization representative job description example 1
NTT Data International L.L.C. prior authorization representative job description
NTT DATA Services strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.
We are currently seeking a Pharmacy Appeals Prior Authorizations Representative to join our team in Lincoln, Rhode Island (US-RI), United States (US).
NTT DATA Services currently seeks a Coordinator - Associate Eligibility Consultant to join our team. If you feel you are qualified by the description below, please apply for a chance to interview and discuss your skills & qualifications.
Job Description:
The position will work in accordance with the Center for Medicare/Medicaid Services (CMS) guidelines to ensure regulatory compliance takes place. This position requires a strong focus around accurate and timely customer support to ensure member enrollment. Key Responsibilities are as follows:
* Identifying and processing different types of documents and routing them to the correct area for processing.
* Processing returned mail and updating members addresses
* Meet monthly established quality and productivity goals on a consistent basis
* Follow work instructions regarding enrollment tasks
Experience:
* 1 year of overall related experience of Center for Medicare/Medicaid Services (CMS) guidelines for Medicare Part D enrollment processes or previous work experience in regulatory environment
Education:
High School diploma or GED
About NTT DATA Services
NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.
NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.
We are currently seeking a Pharmacy Appeals Prior Authorizations Representative to join our team in Lincoln, Rhode Island (US-RI), United States (US).
NTT DATA Services currently seeks a Coordinator - Associate Eligibility Consultant to join our team. If you feel you are qualified by the description below, please apply for a chance to interview and discuss your skills & qualifications.
Job Description:
The position will work in accordance with the Center for Medicare/Medicaid Services (CMS) guidelines to ensure regulatory compliance takes place. This position requires a strong focus around accurate and timely customer support to ensure member enrollment. Key Responsibilities are as follows:
* Identifying and processing different types of documents and routing them to the correct area for processing.
* Processing returned mail and updating members addresses
* Meet monthly established quality and productivity goals on a consistent basis
* Follow work instructions regarding enrollment tasks
Experience:
* 1 year of overall related experience of Center for Medicare/Medicaid Services (CMS) guidelines for Medicare Part D enrollment processes or previous work experience in regulatory environment
Education:
High School diploma or GED
About NTT DATA Services
NTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100.
NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.
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Prior authorization representative job description example 2
Centene prior authorization representative job description
You could be the one who changes everything for our 26 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
• Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
• Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Enter and maintain pertinent clinical information in various medical management systems
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current State LPN/LVN or RN license.
For New Hampshire Healthy Families: Candidates with active nursing licenses in good standing in other states than NH, must obtain the NH equivalent within 90 days of hire. : Active driver's license in good standing preferred.
For North Carolina only: In addition, these individuals will conduct utilization management activities, including but not limited to prior authorization, concurrent review and retrospective review. Must reside in North Carolina, and be NC licensed nurse and/or licensed behavioral health professional in good standing.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
**TITLE:** Prior Authorization Nurse I
**LOCATION:** Tempe, Arizona
**REQNUMBER:** 1363089
Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
• Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
• Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
• Educate providers on utilization and medical management processes
• Provide clinical knowledge and act as a clinical resource to non-clinical team staff
• Enter and maintain pertinent clinical information in various medical management systems
Education/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred.
Licenses/Certifications: Current State LPN/LVN or RN license.
For New Hampshire Healthy Families: Candidates with active nursing licenses in good standing in other states than NH, must obtain the NH equivalent within 90 days of hire. : Active driver's license in good standing preferred.
For North Carolina only: In addition, these individuals will conduct utilization management activities, including but not limited to prior authorization, concurrent review and retrospective review. Must reside in North Carolina, and be NC licensed nurse and/or licensed behavioral health professional in good standing.
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
**TITLE:** Prior Authorization Nurse I
**LOCATION:** Tempe, Arizona
**REQNUMBER:** 1363089
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Prior authorization representative job description example 3
CVS Health prior authorization representative job description
The representative is the initial point of contact for Prior Authorization requests from members, providers, and a diverse customer base. The representative will make determinations if a complex request should be transferred to a technician or pharmacist for assistance. Additionally, they are responsible for maintaining complete, timely, and accurate documentation of all approvals and denials.
To be successful in this role, you will need proficiency in pronouncing drug names and diagnoses and recognizing medical terminology. As well as navigating multiple software systems to document conversations and outcomes, which require keyboarding skills.
This is a call center environment and the representative will be required to take inbound calls.
* This position could require mandatory overtime.
* Important this requisition is for the second shift. 12pm-8pm CST
We offer a comprehensive benefits package that includes medical, dental, and vision insurance as well as a wide-ranging list of supplemental benefits and discount programs. In addition to sixteen paid days off for employees, we also offer ten paid holidays.
Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.16
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
All training will be provided virtually.
Required to provide high-speed internet.
Private dedicated workspace.
Preferred Qualifications
* Previous experience in pharmacy or healthcare industry
* 1+ years' experience in customer service or call center environments.
Pharmacy Tech License is a plus.
Education
Verifiable High School Diploma, GED, or equivalent.
Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
To be successful in this role, you will need proficiency in pronouncing drug names and diagnoses and recognizing medical terminology. As well as navigating multiple software systems to document conversations and outcomes, which require keyboarding skills.
This is a call center environment and the representative will be required to take inbound calls.
* This position could require mandatory overtime.
* Important this requisition is for the second shift. 12pm-8pm CST
We offer a comprehensive benefits package that includes medical, dental, and vision insurance as well as a wide-ranging list of supplemental benefits and discount programs. In addition to sixteen paid days off for employees, we also offer ten paid holidays.
Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.16
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
Required Qualifications
All training will be provided virtually.
Required to provide high-speed internet.
Private dedicated workspace.
Preferred Qualifications
* Previous experience in pharmacy or healthcare industry
* 1+ years' experience in customer service or call center environments.
Pharmacy Tech License is a plus.
Education
Verifiable High School Diploma, GED, or equivalent.
Business Overview
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
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Updated March 14, 2024
Updated March 14, 2024