Prior Authorization Navigator

Scope of Position

The Ohio State University Health Plan is committed to delivering high-quality pharmacy benefit services to all plan participants. The Plans Pharmacy Prior Authorization Navigator (PAN) is responsible for achieving operational excellence as it relates to efficiently and effectively managing all operational aspects of the Plans Medication Utilization Management program, which includes but is not limited to, acting as the primary responsible party for maintaining internal and external vendor prior authorization functionality (ie, OnePA, L2H, Tapestry), educating prescribers, pharmacists and prior authorization coordinators on technology features and medication use criteria, coordinating all medication-related appeals, and collaborating with patients and providers to streamline approval authorizations and denial decisions. The PAN works collaboratively with directors, managers, and clinicians to ensure delivery of innovative, cost-effective, high quality and personalized health care services in an accessible, patient-friendly focused atmosphere. They serve as the subject matter content expert and change agent with in-depth knowledge of managing and resolving medication requests for the pharmacy benefit services department. They manage challenging medication appeals, demonstrate a robust understanding of provider prescribing patterns, communicate approval and denial trends to health plan leadership, and advocate for successful outcomes for all Plan participants. The individual must be capable of identifying trends and offering suggestions for process improvement to streamline workflows and coordinating with other teams to ensure access to the most cost-effective medications. This position is an integral leader on the pharmacy benefit services team.

Position Summary

The PAN is responsible for managing the pharmacy benefit service departments Medication Prior Authorization program from provider submission to Plan decision. They work with internal and external vendors/counterparts to ensure the prior authorization submission, documentation, and decision systems are in working order, they ensure the plan meets all constricted turnaround times on medication requests, and that patients and providers are in receipt of clear and comprehensive rationale for Plan decisions. The PAN is also responsible for identifying trends in approvals and denials, engaging in challenging yet productive conversations with patients and prescribers on medication access status, and delivering education to the clinical operations team around recommended criteria and/or workflow updates. The PAN requires exceptional communication, interpersonal, and organizational skillsets.

The PANs responsibilities include advanced knowledge and understanding of health plan policies and provider prescribing patterns. They manage requests for medication approvals, including assembling and interpreting patient clinical information. The PAN ensures comprehensive care of the patients medication needs through accurate and timely authorization processes. Additionally, the PAN must successfully engage with prescribers, nurses, supporting staff, and other customer groups to ensure accurate and timely claims resolution. The PAN must be able to navigate multiple electronic medical record systems to obtain and interpret pertinent medical information for the prior authorization process, including the determination of whether medication is being used within or outside FDA labeling, relevant lab results, and clinical condition progression.

The PAN participates and leads portions of the pharmacy departmental processes for improvement and training of new and existing staff. The PAN will also be expected to be involved with process improvement and internal quality reviews.

Minimum Qualifications

• Professional licensure in other health-care discipline or PTCB CPhT required.

• Minimum 3 years of pharmacy prior authorization experience or relevant experience preferred.

• Bachelors degree or equivalent experience is preferred. Advanced experience in finance, insurance, insurance appeals, medication and medical terminology desired.

• Ability to work in self-directed manner while interacting with patients, prescribers and all medical center faculty and staff while proactively preparing for medication needs.

• Ability to communicate clearly with health care team.

• Familiarity with OSUMC and its entities preferred.

• Strong demonstrated communication skills.

• Advanced experience with Windows, Excel, Access, PowerPoint, and intranet/internet navigation tools as well as system content.

• Must be highly organized, detail oriented, and able to manage multiple projects at a time.

• Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes.

• Excellent verbal and written communication skills required.

• Advanced competency in the use of computer-based research and medical record documentation required.

Ongoing

• Maintain professional licensure in other health-care discipline or PTCB CPhT required.

• Maintains continuing education requirements on job-related topics to maintain credentials.

• Stays current in disease states associated treatment modalities.

• Meets mandatory educational and health requirements as well as ongoing department competencies.

Our Comprehensive Employee Benefits Include

• An array of retirement plan options, each with a generous employer contribution.

• Affordable health insurance options, including dental, vision and prescription coverage that begin on day one.

• Paid vacation and sick leave, including short and long-term disability and paid parental leave.

• Get the most out of the Public Service Loan Forgiveness program.

• And much more!