Workers Compensation Pharmacy Prior Authorization Representative The client is a full-service Workers Compensation Pharmacy Benefit Management company focused on patient advocacy. By combining clinical expertise and advanced business analytics, it simplifies workers compensation claims management while providing safer medication therapy management.
Position Summary: The Pharmacy Prior Authorization Representative manages the end-to-end prior authorization process for Workers Compensation pharmacy benefits from receiving and responding to authorization inquiries to researching issues, coordinating with stakeholders, and ensuring regulatory compliance. This role supports injured workers, pharmacies, prescribers, client adjusters, and third-party billers by providing guidance on claims submission, workflow processes, and state-specific requirements.
The ideal candidate combines strong communication and problem-solving skills with the ability to navigate proprietary systems, interpret regulatory guidelines, ensure compliance with client and state Workers Compensation regulations, and effectively document, resolve, and escalate issues as needed.
Roles and Responsibilities:
Handle inbound and outbound injured workers, provider, adjuster, pharmacy and internal/external stakeholder calls, chats, emails, and interactive memos.
Complete work within a proprietary system, according to the assigned tasks.
Execute tasks according to Standard Operating Procedures, Client, and Workers Compensation juris states regulatory requirements.
Support pharmacies, prescribers, and internal/external stakeholders regarding inquiries and or issues related to Prior Authorization eligibility, rejections, and authorization management.
Maintain productivity standards, quality assurance, performance guarantees, and regulatory compliance.
Work with internal/external stakeholders to research and resolve mail order, specialty and retail pharmacy claims issues and respond within performance agreement guidelines and/or regulatory requirements.
Maintain accurate, complete, and compliant documentation of all inquiries and resulting action.
Identify and escalate concerns received from injured workers, 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 requirements.
