Pharmacy Authorization Representative II

Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.   

As a Pharmacy Authorization Representative II, you will ensure optimal reimbursement for high-cost injectable medications and be responsible for conducting, completing and following-up with activities for third party prior authorization requests for high-cost medications. 

A caregiver in this role works remotely in Ohio or Florida from 8:00 a.m. – 4:30 p.m.

A caregiver who excels in this role will:

• Cross trained to work in all areas of authorizations supporting any institute or facility with minimal leadership guidance. 

• Act as a resource for training new team members and during the implementation of new processes. 

• Perform follow-up activities for pending status prior authorizations in accordance with standard operating procedures.   

• Obtain medical benefit and or pharmacy benefit authorizations via payer portal, by phone or fax. 

• Retrieve correct clinical information from various sources (i.e. office notes, labs, and other relevant reports) within electronic medical records for submission.

• Communicate with providers, clinical caregivers and office caregivers to obtain clinical information and/or coordinate peer-to-peer conversations. 

• Review payer websites for medication changes and update related to authorization submissions. 

• Communicate with providers and clinical caregivers to assess medical necessity to support complete authorization submission. 

• Collaborate with Financial Navigators to assist with Patient Assistance program enrollment.   

• Facilitate adherence to Medicare requirements including knowledge of Medicare Local Coverage Determinations (LCDs) and Payer Clinical/Medical Policies. 

• Maintain productivity and quality expectations set forth by department. 

Minimum qualifications for the ideal future caregiver include:  

• High School Diploma or GED and three years of prior authorization and/or pre-certification medication experience, outpatient healthcare experience or other relevant experience

• OR Associate’s degree or diploma/certificate in medical assisting, medical administrative assisting, billing/coding, or other healthcare related field and two years of prior authorization and/or pre-certification medication experience, outpatient healthcare experience or other relevant experience

• Knowledge of medical terminology

• Ability to multitask within multiple accounts in high-volume insurance verification processes

• Demonstrated PC skills in Word, Excel and Outlook

Preferred qualifications for the ideal future caregiver include: 

• Experience with third party billing.

• Knowledge of ICD-10, HCPCS and CPT codes

• Knowledge of healthcare insurance prior authorizations

Physical Requirements:

• Sufficient mobility and strength to move around the department and throughout the facility.

• Ability to stand or sit for prolonged periods of time.

• Excessive walking and standing while obtaining patient information when using laptop computer on wheeled device for bedside registration.

• Ability to lift 25 pounds.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment. 

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic is pleased to be an equal employment opportunity employer.