Award-winning: Sentara is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering more than 500 sites of care including 12 hospitals, PACE (Elder Care), home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!
When you join Sentara in a clinical role, you become part of an interdisciplinary team that is passionate about quality care. Our diverse inpatient and outpatient settings offer the tools and technologies you need to do your best work. All while learning and growing within a culture that embraces opportunity.
AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Pharmacy Prior Authorization Coordinator II in Miami or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.
Scope of the position: Under the direction of a Pharmacy Team Coordinator (TC), the Pharmacy Prior Authorization Coordinator II (PAC II) is responsible for supporting the day-to-day operations for the call center and prior authorization cases for all lines of business (, Medicare, Exchange and Commercial).
Provides knowledgeable and courteous customer service and response to members and providers. Handles member/provider requests/inquiries regarding pharmacy benefits, prior authorizations, or claim resolution. Uses the pharmacy computer system to facilitate prior authorizations and participate in patient/provider/ customer care activities that do not require the expertise of a pharmacist.
Serves as a resource and mentor to pharmacy staff and assists TC with workflow oversight for the pharmacy call center and prior authorization operational teams. Assists with special projects and assignments and maintains above average knowledge of all pharmacy related applications to assist in workflow performance. Serves as an internal resource interfacing with members, providers, and internal staff to resolve escalated pharmacy claims and prior authorization issues. Owns the effective resolution of member or provider issues, complaints, and inquiries, focusing on high member satisfaction.
Essential Job Functions:
• Reviews and triage faxes/e-mail PA requests from Members, Physicians, Pharmacists, and other providers requesting coverage of formulary and non-formulary agents, drug benefit exceptions, and overrides on drugs subject to formulary management programs.
• Serves as AvMed’s subject matter expert in resolving escalated Member, Provider, or Client pharmaceutical related inquiries and/or issues in an accurate, timely, and courteous manner.
• Reviews and approves payment for high-cost pharmaceutical claims.
• Monitors, performs, and documents daily compliance activities.
Reviews and processes member reimbursements within appropriate time frames.
Minimum Requirements:
• High School Diploma
• 2 years of Pharmacy Call Center or Authorization experience required
• Bilingual in Spanish
• Florida Pharmacy Technician or National Certified PTCB Technician required
Preferred Qualifications:
• 2 years of Managed Care, Health Plan or PBM experience preferred
• Microsoft Office
• Creating word documents, communicating with team via Outlook
• Ability to work in Excel
• Excellent verbal and written communication skills
• Ability to function effectively in a busy office environment
• Time Management
• Willingness and ability to function both independently and as a team member
Our Benefits
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
• Medical, Dental, and Vision Insurance
• Paid Annual Leave, Sick Leave
• Flexible Spending Accounts
• Retirement funds with matching contribution
• Supplemental insurance policies, including legal, Life Insurance and AD&D among others
• Work Perks program including discounted movie and theme park tickets among other great deals
• Opportunities for further advancement within our organization
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits – Sentara (sentaracareers.com)
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.
Keywords: Talroo-health Plan, #Indeed, Pharmacy Call Center, Authorization experience, Florida Pharmacy Technician or National Certified PTCB Technician
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Sentara prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
