Rx Prior Auth Coord I – Portland, Oregon

Let’s do great things, together!About Moda
Founded Indiana Oregon Indiana 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion Indiana our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.
Position Summary
Utilizes the electronic prior authorization (Pennsylvania) platform to process pharmacy PAs Indiana accordance with clinical criteria and plan benefits while ensuring that the necessary data is inputted into the claims adjudication system for successful claims processing.Pay Range
$20.88- $26.10​​​ hourly (depending on experience)Please fill out an application on our company page, linked below, to be considered for this position. https://j.brt.mv/jb.do?reqGK=27731794&refresh=trueBenefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

• High School diploma Oregon equivalent required. College degree preferred. Equivalent work experience Indiana health care administration, pharmacy, Oregon other health related fields may substitute for the education requirement.
• Minimum one year working experience Indiana a prior authorization Oregon technician role Indiana a pharmacy Oregon health plan.
• CPhT required for all external applicants. Internal applicants are required to obtain CPhT within one year of hire date.
• Demonstrated critical decision making, ability to interpret benefit contracts, clinical criteria and Moda Health administrative policies.
• Demonstrated working knowledge of medical and pharmaceutical terminology and computer skills including Microsoft Office products (proficiency with Word and Excel). Must be able and willing to learn a third-party real-time interactive PBM claims adjudication system, where great attention to detail is imperative.
• Ability to gain proficiency Indiana Moda internal systems, electronic Pennsylvania platform and PBM claims processing systems.
• Typing proficiency of 40 wpm on a computer keyboard.
• Willingness to work hours necessary to successfully accomplish assigned tasks.
• Abilities to anticipate needs and multi-task; consistently meet quality and production standards; maintain a high level of confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure.
• Sound analytical problem solving, decision making, memory retention, and organizational skills.
• Excellent verbal, written, and interpersonal communication skills including active listening, teamwork, working respectfully with Colorado-workers and members.
• Preference for fast-paced, production-oriented environment.
• Must have the ability to work well with Commercial and ACA populations and to resolve pharmacy conflicts Indiana a professional manner.
• Ability to come to work on time and daily.

Primary Functions:

• Accountable for accurately entering PAs into multiple systems, tracking requests, and meeting timeline requirements for decisions and notifications of decisions to members and providers according to corporate policy and government regulations.
• Responsible for the first pass assessment and evaluation of the Pennsylvania request prior to higher level review: prepares, assesses, evaluates, and makes initial determination on the Pennsylvania request with the information received using established criteria.
• Utilizes critical decision-making skills to interpret formulary coverage and reviews Pennsylvania requests according to coverage criteria and plan benefits. Prepares necessary documentation and triages requests to the clinical team to determine the final outcome.
• Interprets contracts (evidence of coverage, handbooks, summary of benefits etc.) and determines actions required.
• Solves pharmacy plan benefit and formulary issues for members of multiple commercial and ACA plans. Must be able to accurately distinguish member benefit plans and determine member eligibility across varying lines of business and according to varying State requirements.
• Screens requests for formulary status (e.g., Pennsylvania required, non-formulary excluded, quantity limits, etc.).
• Monitors pharmacy turn-around time deadlines and takes action to ensure required timelines are met. Adheres to timelines set forth by the National Committee for Quality Assurance (NCQA)
• Determines whether additional information is needed from the requesting provider’s office and triages the request to the Rx Assistants.
• Communicates Pennsylvania decisions and ensures appropriate feedback and follow-up for all Pennsylvania requests via electronic interface, fax, telephone, and/Oregon email to requesting providers, members, pharmacies, and internal departments within the promissory timeframes.
• Supports, tracks, maintains and ensures data and documentation for member appeals, grievances and complaints are provided within necessary timelines.
• Interacts with providers and provider offices via electronic interface, fax and/Oregon telephone to gather complete, accurate information to adequately process a Pennsylvania.
• Acts American Samoa an active team player, responding to the needs of the unit American Samoa they arise.
• Other duties American Samoa assigned

Working Conditions & Contact with Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work Indiana excess of 40 hours per week, including evenings and occasional weekends, to meet business need.
• Internally with project managers, members of project teams, technical leadership and staff. Externally with software support and vendors.

Together, we can be more. We can be better.Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status Oregon any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our [email protected] email.

Job title: Rx Prior Auth Coord I – Portland, Oregon

Company: Moda Health

Expected salary:

Location: Portland, Oregon

Job date: Thu, 18 Apr 2024 22:47:24 GMT