Pharmacy Prior Authorization Representative - Remote

Receives and responds to inquiries regarding Prior Authorizations related to Worker's Compensation pharmacy benefits.

Interacts with injured workers, providers, adjusters, pharmacies and internal/external clients via multiple forms of communication.

Assist pharmacies and adjusters in understanding the pharmacy benefit claims submission, workflow and authorizations process.

Assist injured workers in understanding and maximizing the use of their workers compensation pharmacy benefit program.

Use computerized system to gather information and respond to questions.

Works to research and resolve problems in a timely manner.

Documents issues and resolutions and communicates results to appropriate parties.

Uses resources and specific protocols to escalate issues as necessary.

Essential Functions


* Handle inbound and outbound injured worker, provider, adjuster, pharmacy and internal/external client calls, chats, emails and interactive memos.


* Execute tasks according to Standard Operating Procedures, Client Requirements and Regulatory Requirements.


* Support pharmacies, providers and internal/external clients regarding inquiries and or issues related to Prior Authorization eligibility, rejections, and authorizations.


* Maintain productivity standards, quality assurance and performance guarantees.


* Work with other operational departments to research and resolve mail order and retail pharmacy claims issues and respond to clients and other business partners within performance agreement guidelines.


* Maintain accurate and complete documentation of all inquiries and resulting action.


* Identify and escalate concerns received from patients, pharmacies or clients so that corrective action can be pursued in a timely manner.


* Responsible for good housekeeping techniques, adhering to quality and production standards while complying with all applicable company, state and federal safety


* Other duties as assigned

Qualifications


* High school diploma or GED required


* 1 year of relevant experience preferred


* General PC knowledge including Microsoft Office and Internet


* Excellent verbal presentation and written communication skills


* Ability to handle challenging customers in a professional manner


* Ability to adapt in a dynamic work environment


* Learns quickly, solve problems and make decisions


* Willingness to work a schedule within the department hours of 6am to 10pm EST that may include a weekend day

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality.

We relentlessly innovate to make the prediction, prevention and treatment of il...