San Antonio, TX
- Will work closely with providers to process prior authorization (PA), and drug benefit exception requests on behalf of Aetna as the client and in accordance with Medicare Part D CMS Regulations.
- Must apply information [provided through multiple channels] to the plan criteria defined through work instruction.
- Research and conduct outreach via phone to requesting providers to obtain additional information to process coverage requests and complete all necessary actions to close cases. Responsible for research and correction of any issues found in the overall process.
- Phone assistance is required to initiate and/or resolve coverage requests.
- Escalate issues to Coverage Determinations and Appeals clinical pharmacists and management team as needed.
- Must maintain compliance at all times with CMS and department standards.
- Working incoming cases via phone (primarily) or fax to process coverage requests from members or prescribers.
- Conducting outreach to patients and providers, and obtaining additional information needed to process requests.
- Researching and correcting any issues found in the overall process.
- Raising issues to Coverage Determination.
- Clinical Pharmacists and Management team as needed.
- Reading, analyzing, and interpreting general business correspondence, technical procedures, and governmental regulations.
- Solving practical problems and dealing with multiple concrete variables in standardized situations.
- Performing basic mathematical calculations.
- Ensuring all cases are properly closed.
- Schedule flexibility including rotations through Nights, Saturdays and minimal Holiday Coverage.
Required Skills, Experience and Abilities Qualifications:
- 6+ months of customer service, pharmacy or related experience.
- Position requires schedule flexibility including rotations through nights, weekend and holiday coverage.
- Strong Attention to detail.
- Excellent verbal and written communication and interpersonal skills w/ ability to maintain patient confidentiality.
- Proficient computer skills and the ability to navigate in a Windows based environment.
- Ability to follow directions, and adapt in dynamic work environment; ability to adapt to change and remain flexible.
- Ability to work in a high pressure, time sensitive environment.
- Project a professional business image, through phone interaction as well as internal communications.
- Demonstrated problem-solving ability and attention to detail.
- Demonstrated sense of urgency with assignments.
- Strong organizational skills.
- Strong telephone skills.
- Ability to read and understand pharmacy/medical terminology.
- Ability to read, analyze and interpret general business correspondence, technical procedures and governmental regulations.
- Ability to identify and solve practical problems and deal with a variety of concrete variables in standardized situations.
- Ability to perform basic mathematic calculations maybe required.
- Ability to interpret a variety of work instructions provided through a variety of mediums.
- Ability to anticipate needs and resolve issues with urgency.
- Ability to consistently meet quality and production standards.
- Displays confidence in the ability to learn complex material.
- Demonstrates intellectual curiosity through inquiries to ensure deep understanding of the business and deliver accurate results
Preferred Skills, Experiance and Abilities Qualifications:
- Call center experience Pharmacy or PBM environment highly preferred Experience in a role requiring maintenance of patient confidentiality.
- Proficient computer skills and the ability to navigate in a Windows based environment including ability to toggle between multiple programs, ability to navigate web based systems as well as DOS based systems, and adaptable to system changes and upgrades.
- Verifiable High School Diploma or GED required.
For more information, please contact A-Line Staffing Solutions at 877-782-3334.