About AmeriPharma
AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.
AmeriPharma’s Benefits
- Full benefits package including medical, dental, vision, life that fits your lifestyle and goals
- Great pay and general compensation structures
- Employee assistance program to assist with mental health, legal questions, financial counseling etc.
- Comprehensive PTO and sick leave options
- 401k program
- Plenty of opportunities for growth and advancement
- Company sponsored outings and team-building events
- Casual Fridays
Job Summary
Prior Authorization Coordinator I plays a critical role in the patient care continuum by executing accurate, timely medical insurance verification and securing essential prior authorizations. Operating at the intersection of clinical care and revenue cycle management, this position ensures patients receive prompt access to life-altering specialty medications and home infusion therapies while safeguarding the organization against financial risk and enabling seamless reimbursement.
Schedule Details
Location: Fully On-Site, Laguna Hills, CA
Schedule: Monday - Friday 8:00AM-5:30PM
Duties & Responsibilities
Intake, Screening & Insurance Verification
- Order Triaging: Screen and prioritize orders requiring benefits investigation and medical prior authorization.
- Profile Review: Review the completeness of payers documented in each patient’s insurance profile, verifying accuracy of insurance setup, plan types, and payer categories.
- Coordination of Coverage: Identify patient’s primary, secondary, tertiary, or supplemental plans alongside the authorizing group.
- Eligibility Tracking: Generate and utilize reports to track ongoing monthly patient eligibility verifications.
- Network Status Guidance: Identify and inform providers and patients regarding network providers and the organization's network participation status.
Prior Authorization & Case Management
- PA Submission: Submit prior authorization requests to medical plans and coordinate the review of cases requiring clinical judgment with clinical staff.
- Reauthorizations: Generate expiring medical authorization reports and proactively initiate reauthorization requests to ensure continuity of care without delay.
- Caseload Management: Maintain a full caseload while meeting or exceeding designated operational metrics and turnaround timeframes.
- Pharmacy Support: Run pharmacy test claims and contact payers to verify member
Communication & Documentation
- Payer Correspondence: Document all communications with insurance plans, including the representative's name, phone number, and call reference number.
- Account Updating: Document detailed medical authorization status updates on patient accounts accurately and promptly.
- Provider & Patient Liaison: Answer inbound medical authorization calls, providing high-level customer service to patients, doctors' offices, and internal departments.
- Clinical Info Retrieval: Obtain and communicate necessary clinical information or medical records directly with providers to appeal denied or pending authorizations.
- Coverage Shifts: Identify changes in patient medical plan coverage, update assigned orders, and coordinate new payer information with Billers to ensure accurate claim submission.
Compliance & Performance Tracking
- Task Follow-up: Create and utilize reminders and follow-up reports to ensure completion of all pending or incomplete activities.
- Management Escalation: Escalate unresolved benefits investigations and prior authorization issues to management after proper internal resolution attempts have been made.
- Regulatory Alignment: Ensure strict compliance with all payer rules, regulations, and company policies.
- Other Duties: Perform alternative tasks and duties as assigned by leadership.
Required Skills
- Communication: Ability to read, write, speak, and understand the English language. Strong interpersonal skills with a service-oriented mindset.
- Collaboration: Ability to support colleagues in a fast-changing environment and cooperate across teams for all pharmacy needs.
- Critical Thinking: Ability to apply common sense understanding, logical thinking, and data analysis to resolve abstract and concrete problems.
- Work Management: Excellent time management, multi-tasking, and prioritization skills with the ability to work independently under minimal guidance.
- Technical Aptitude: High accuracy in typing and data entry.
- Flexibility: Ability to work the hours required to ensure all projects and daily duties are completed in a timely manner.
Required Qualifications
- Associate’s Degree
- At least 2 years of experience in specialty pharmacy, home infusion, medical billing, and medical/pharmacy authorization processes.
- Experienced as a medical coder/biller with a working knowledge of managed care, commercial insurance, Medicare, and Medicaid reimbursement.
- Knowledge of ICD 10, CPT, HCPC and J billing codes and medical terminology, with CMS HCFA 1500 form & Electronic Billing. Knowledge of Benefit Investigation and Patient Responsibility Agreements.
- Knowledge of automated billing systems. Advanced knowledge of Word, Excel, and Outlook functions.
AmeriPharma’s Mission Statement
Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential fun