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Prior Authorization Specialist
Polaris Pharmacy Services. Manage and identify a portfolio of rejected pharmacy claims .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing pharmacy claims, including analyzing and resolving rejected claims with Medicare Part D and third-party insurance. Proficient in compliance with HIPAA regulations and maintaining accurate processing reports.
Highest-signal resume keywords
Pharmacy Technician ExperienceClaims ManagementHIPAA ComplianceMicrosoft Office ProficiencyCustomer Service Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AnalysisData EntryBasic Math SkillsAnalytical Skills10-Key Number EntryPrior Authorization ProcessingRevenue MonitoringPayer Reimbursement MaximizationProblem SolvingAttention to Detail
Soft Skills
Results-OrientedGood OrganizationAdaptabilityReliabilityCommunication Skills
Tools & Technologies
Microsoft WordMicrosoft ExcelMicrosoft OutlookFramework LTC
Industry Keywords
Medicare Part DThird-Party InsuranceState Medicaid PlansPharmacy ClaimsCorporate Compliance AgreementFederal and State Laws
About the role
Key responsibilities & impact- Manage and identify a portfolio of rejected pharmacy claims
- Research, analyze, and resolve rejected claims with Medicare Part D plans, third-party insurance companies, and state Medicaid plans
- Perform edits and reversals to secure claim approvals and maximize payer reimbursement
- Contact providers and facility contacts to obtain additional information
- Monitor and resolve revenue at risk related to payer setup, billing, rebilling, and reversal processes
- Identify, document, communicate, and resolve payer and billing trends and issues as part of a team
- Complete, communicate, and submit prior authorization forms promptly
- Support training needs
- Prepare and maintain processing reports and records
- Follow applicable government regulations, including HIPAA
- Comply with departmental safety, attendance, and dress-code policies
- Conduct responsibilities according to the company Code of Business Conduct and Ethics, policies, Corporate Compliance Agreement, federal and state laws, and professional standards
- Perform other assigned duties as business needs require
Requirements
What you’ll need- High School diploma or equivalent required
- Minimum of one or more years working as a pharmacy technician in a retail environment preferred; long-term care pharmacy preferred
- Framework LTC and general computer knowledge preferred
- 10-key number entry preferred
- Able to read, write, speak, and understand English
- Able to retain a large amount of information and apply that knowledge to related situations
- Able to work in a fast-paced environment
- Basic computer knowledge skills required
- Basic math and analytical skills
- Experience with alphanumeric data entry
- Proficient in Microsoft Word, Excel, and Outlook required
- Customer service skills
- Results-oriented
- Good organization and attention to detail
- Reliable and able to solve problems
- Able to work various shifts and days
- Adaptability to an ever-changing environment
- May need to work overtime, holidays, and weekends
- May sit or stand seven to ten hours per day
- May lift and/or move up to 30 pounds
- Must follow HIPAA, applicable laws, company policies, and professional standards
Benefits
Comp & perks- Paid holidays: 6 days annually
- 5 sick days annually
- Up to 10 PTO days annually, with rollover options and milestone bonuses
- Option to cash out up to 10 PTO hours each quarter
- Medical, Dental, and Vision insurance
- 401(k), available for part-time and full-time employees
- Company-paid life insurance
- Short-term and long-term disability insurance
- Tuition reimbursement
- Competitive pay with annual performance reviews and merit-based raises
- Career growth potential
- Annual on-site voluntary flu vaccines
- Employee referral bonus program