Description:
Simplex Pharmacy is a busy, independent pharmacy in Brooklyn, NY, dedicated to exceptional patient care. Our leadership team is looking for a top-tier, expert-level Prior Authorization Specialist to join us as an exclusive, full-time remote partner.
This is a critical, high-trust role for a "PRO" who can independently manage our entire prior authorization and appeals process from end to end with minimal supervision. We need a problem-solver who can navigate the complexities of the US insurance system to ensure our patients get their medications without delay.
Key Responsibilities:
- End-to-End PA Management: Independently manage the complete PA workflow for all prescriptions, specializing in high-cost, specialty, and non-formulary medications.
- Benefits Investigation: Conduct meticulous verification of patient insurance eligibility, benefits, co-pays, and deductible status.
- Clinical Review & Submission: Collaborate with prescribers' offices to gather necessary clinical documentation (chart notes, lab results, therapy failure history) to build a strong case for approval.
- Denial & Appeal Management: Aggressively follow up on all pending requests. When a PA is denied, you will analyze complex denial codes (e.g., CO 50, PR 23) , immediately initiate the appeals process, and manage multi-level appeals, including Medicare Part D Redeterminations and Reconsiderations.
- System & Platform Proficiency: Accurately submit and track requests using ePA platforms (e.g., CoverMyMeds, Surescripts) and directly through PBM portals (e.g., CVS Caremark, Express Scripts, OptumRx).
- Stakeholder Communication: Serve as the primary liaison between our pharmacy, US-based insurance companies, and prescribers' offices. You must be able to argue persuasively and prepare documentation for peer-to-peer review calls.
- Documentation: Maintain meticulous, HIPAA-compliant records of all requests, communications, denials, and approvals within our pharmacy's EHR/EMR system.
Must-Have Qualifications (Non-Negotiable)
- Experience: 3-5+ years of direct, hands-on experience in prior authorization, specifically for a U.S.-based pharmacy or healthcare provider.
- U.S. Healthcare Knowledge: Expert-level understanding of the US healthcare system, including PBMs, Medicare Part D, and Medicaid.
- Appeals Expertise: A proven track record of successfully managing and overturning complex denials, including "Step Therapy" and "Medical Necessity" appeals.
- Communication Skills: Exceptional (C1/C2 Level) English verbal and written communication. Must be confident, persuasive, and professional in negotiations with insurance agents and clinical staff.
- Technical Skills: Proficiency with EMR/EHR systems and e-authorization platforms like CoverMyMeds or Surescripts.
- Work Ethic: Highly organized, self-motivated, and detail-oriented. Must have a proven ability to work independently in a remote EST-based schedule.
- Exclusivity: Ability to commit to a full-time, exclusive role dedicated solely to Simplex Pharmacy.
- Remote Setup: A quiet, private home office with high-speed, reliable internet and a backup power solution (UPS/generator) to ensure 100% uptime during work hours.