Authorization Representative II - BioPlus Specialty Pharmacy

Job Description Pharmacy Prior Authorization Specialist - BioPlus Specialty Pharmacy Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. BioPlus Specialty Pharmacy is a proud member of the Elevance Health family of companies . BioPlus offer consumers and providers an unparalleled level of service that’s easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, we deliver an elevated experience, affordability, and personalized support throughout the consumer’s treatment journey. The  Pharmacy Prior Authorization Specialist will be responsible for the administration of prior authorizations requests for patients whose health plan requires drug prior authorizations for different therapy types. How you will make an impact: Reviews accuracy and completeness of prior authorization information requested and ensures supporting documents are present and meet company set standards. Assists with the completion of medical necessity documentation to expedite approvals and ensures that appropriate follow up is performed. Collaborates with other departments to assist in obtaining prior authorizations/appeals. Documents insurance company interactions and all prior authorization information in the system. Reviews insurance denials and submits appeals as permitted by payor. Contacts physician offices as needed to obtain demographic information or medical data.

Requires a HS diploma or GED and a minimum of 2 years of experience processing pharmacy prior authorizations, and a minimum of 1 year of experience applying knowledge of Medicare, Medicaid and Managed Care reimbursement guidelines; or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities and Experiences: Specialty pharmacy experience highly preferred. Medical terminology training is preferred. Prior Authorization experience is highly desired. Use critical thinking to interpret oncology regimens and supporting clinical documentation, anticipates payer criteria (e.g., step therapy, site-of-care, NCCN-guided rationale), and determine the best authorization strategy and next step is desired. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: CUS > Care Support Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our