At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job Title

Pharmacy Authorization Representative II

                        

Location

Cleveland

                    

Facility

Remote Location

                     

Department

RCM Pre Access-Finance

                      

Job Code

001270

                     

Shift

Days

                       

Schedule

8:30am-5:00pm

                       

Job Summary

                         

Job Details

This position is 100% remote - Must be a resident of OH or FL only.

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. 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.

 

Medical exposure with office or coding is preferred must have some form of clinical exposure (ex - MA, Coder or auth experience)

At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.

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. 

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities