Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as the No. 4 hospital in the nation, according to the U.S. and World News Report. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

Under the guidance of the Department Manager, the Pharmacy Authorization Representative ensures optimal reimbursement for high cost injectable medications and is primarily responsible for conducting, completing and follow up activities for necessary third party prior authorization requests for high cost medications. The Pharmacy Authorization Representative is a position residing in the Pharmacy Department.

Cleveland Clinic provides what matters most: career growth, delivering world-class care to our patients, continuous learning, exceptional benefits and working for an organization that offers many long-term career paths. Join us and experience a culture where opportunities to advance and the support to get there go hand-in-hand.

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.