Navitus

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other._____________________________________________________________________________________________________________________________________________________________________________________________________________. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities.

USD $17.78 - USD $20.91 /Hr.

Varies M-F 8am-8pm CT, Weekends and Holiday rotations

ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Navitus Health Solutions is seeking a Medicare Prior Authorization Specialist I to join our Prior Authorization Department?

 

The Medicare Prior Authorization Specialist I (MPAS I) will review, process, and troubleshoot incoming Medicare Coverage Determination requests for various medications and against a wide variety of pharmacy benefits, CMS defined regulatory requirements, and formularies. The MPAS I will accurately process the requests according to stringent regulatory and client specifications, which include short turnaround times, unique processes, and with absolute accuracy. The MPAS I will work with other team members to meet the departmental performance metrics and maintain compliance. The MPAS I will process requests received via phone, fax, ePA, and web submission. The Medicare Prior Authorization Specialist I (MPAS I) will be proficient in the Navitus claim processing system, the PA Processing System, knowledge management application, and Intranet. The MPAS I will gain proficiency in understanding, applying, and communicating client-specific formularies, clinical programs, regulatory guidance, and other pharmacy benefit components. The MPAS I will follow all CMS required regulations to ensure accuracy and compliance in 100% of the work performed in Medicare Prior Authorization Specialist role. The MPAS I will understand and apply deep subject matter expertise related to Medicare Part D rules and regulations specific to Coverage Determinations, Redeterminations, and IRE processes.

 

Is this you? Find out more below!

How do I make an impact on my team? 

• Research and analyze pharmacy claim rejections. Ensure the Coverage Determination request is necessary or appropriate based on rejections, claim history, and system messaging
• Aid members, providers, and Appointed Representatives via phone in submitting Coverage Determination requests, provide formulary product information, communicate prior authorization request status, communicate criteria for approval, and communicate and/or gather the additional information needed to process a request
• Create case files within Prior Authorization system for all Coverage Determination requests to include selection of the correct member, provider, medication requested, urgency of the request, and in line with CMS requirements defined by CMS Chapter Guidance and department polices and department resources
• Upon intake of a new request, correctly identify Redeterminations, IRE requests, Manual claim requests, B vs D requests, Additional Information requests, Exception requests, etc
• Review chart notes and Coverage Determination forms to create Coverage Determination case files for clinical and benefit review. Apply information contained in chart notes to prior authorization criteria question sets to include such items as diagnosis, lab values, medications tried with dates of trial and outcomes, provider specialty, etc
• Ensure requests that are not approved through automation are routed to a pharmacist. This includes ensuring all Coverage Determination requests that require clinical decision making or clinical review based on regulatory requirements and department policies are properly routed to a pharmacist
• Have strong knowledge around CMS Coverage Determination timeliness requirements. This includes timeliness related to Urgency, Exceptions, Oral Notification to Members, AOR requests, Reopens, and mail times
• Accurately enter claim adjudication overrides to allow approved prior authorizations to pay within the specific benefit including application to benefit maximums, correct patient pay amounts, pharmacy network restrictions, and limitations such as cost and supply
• Adhere to the Medicare Prior Authorization performance expectations as defined by the Prior Authorization Specialist Competencies
• Other duties as assigned

What our team expects from you?

• High school degree or equivalent
• Post high school education preferred
• Desired post high school education in Medical Terminology, Licensed Practical Nursing, Medical Assistant, Medical Transcriptionist, Business, or Certified Pharmacy Technician
• Two years’ experience in customer service industry, healthcare, or pharmacy required
• Phone etiquette and computer/typing/data entry skills required
• Knowledge of Microsoft Office suite
• PBM or managed care experience desired
• Experience in Medicare Part D Coverage Determination processing highly desired
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

Remote

US