Prior Authorization Pharmacy Coordinator Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,
04/2020 to Current Prior Authorization Pharmacy Coordinator Shields Health Solutions | Kalamazoo, MI,
  • Accurately review and process prior authorization requests for medications through the determination process based on the pharmacy clinical criteria/guidelines.
  • Utilize all applicable policies, procedures and materials used in determining the appropriate review of claims and document.
  • Implement complete accuracy reviewing prior authorization requests submitted and authorize in compliance with all established procedures and the health plan’s pharmacy guidelines.
  • Review clinical notes and extract all pertinent information for proper determination based on clinical criteria's/guidelines.
  • Comprehensibly document all information in accordance with the plan’s guidelines, make approval decisions with the appropriate approval/denial verbiage.
  • Assist providers and pharmacies by troubleshooting pharmacy claims processing and queries regarding prior authorizations.
  • Provide assistance to pharmacies and customer service with applicable overrides and member eligibility and direct information to the appropriate department.
  • Proactively prioritize tasks to ensure workflow procedures to meet turn-around time requirements to sustain regulatory compliance.
  • Send proper correspondence to providers, pharmacies and other departments to obtain additional information (chart notes, lab results) necessary for the review of the requested service.
  • Assist pharmacy department coordinate prior authorization requests.
  • Follow established procedures for authorizing requests and/or refer requests to RPh for clinical review.
  • Effectively uses the health plan’s systems to accurately determine eligibility, benefit plan, and physician networks associated with the member’s plan.
04/2015 to 04/2020 Senior Pharmacy Technician Northshore | Lake Forest, IL,
  • Accurately read, understood, and transcribed abbreviated directions & information from physician's prescriptions onto patient's medication profile.
  • Initiated and processed Prior Authorizations with physicians & third-party insurers to establish the safest and most cost-efficient option for medical therapy.
  • Researched discrepancies & resolved conflicts, communicated with patient's contacting patient, MD and insurance providers.
  • Articulated the health plan pharmacy benefits, drug coverage and explain payment options to patients.
  • Reviewed Medicare and Medi-Cal prior authorization cases for proper determination based on criteria; adjusting according to plan formulary, modifications due to state regulations and dispensing guidelines.
  • Applied the mandated procedures for authorizing requests or referring requests for further review for Treatment Authorization Requests ICD 9/10 codes, CMN forms & Workers Compensation cases.
  • Appointed by pharmacy leadership to refine workflow processes to minimize turn-around time for filling prescriptions.
  • Notified pharmacists when information is lacking and prescription requires further action before entering in Rx.
  • Accurately secured patient’s demographics and medical information to ensure all procedures are in sync with HIPPA compliance and regulations.
  • Consistently followed up with patients on drug changes by searching for out-of-stock drugs for patients, MD office denials, insurance issues, and manufacturer backorder on medications.
  • Ensured that pharmacy inventory meets company standards which included ordering, returning expired & recalled drugs.
12/2015 to 04/2016 Outpatient Pharmacy Technician Kaiser Permanente | City, STATE,
  • Received new prescriptions and/or refills verifying the correct entry/documentation of information required to process the order.
  • Accurately and completely input all prescriptions and patient's data into computer system.
  • Counted, measured and compounded medications, applying labels and verifying accuracy prior to dispensing.
  • Trained and worked under the pharmacist supervision during pharmacy system update at 15 different Kaiser pharmacy locations.
  • Displayed working knowledge of current drug dosage forms, strengths, generic and trade name traditional and current equivalents on a daily basis.
  • Used correct short codes to correspond correct product, package size & strength, doctor's name & directions.
  • Handled membership pharmacy benefit coverage issues by verifying eligibility and appropriate costs.
  • Reconciled daily cash register summary documents and prepared daily combined bank deposit for pharmacy.
Expected in 05/2015 B.A. | Psychology San Jose State University, San Jose, CA GPA:
  • Maintains a strong attention to detail for extended periods of time
  • Cohesive ability to apply good judgement and problem-solving skills
  • Effectively adapts to variable circumstances while proficiently alternating between tasks
  • Remains focused and works efficiently under pressure
  • Extensive experience in delivering outstanding quality customer service experience working with customers queries
  • Professional and effective interactive communication skills with patients of multiple styles with respect and confidence
  • Delivers results while balancing quality and efficiency in all tasks
  • Maintains accuracy while consistently meeting workflow and ensure successful implementation
  • Optimize patients' outcomes by ensuring drug benefits are administered as designed; minimize inconvenience for patients & providers
  • Strong pharmacy math skills; very comfortable using metric measurements, conversions, drug dosage and day supply calculations
  • Strong working knowledge of medical & pharmacy terminology
  • In- depth literacy to follow verbal and written communications and interpret medical abbreviations and sig codes
  • Substantial understanding and recognition of accuracy and legibility of prescriptions
  • Cumulative work experience in Retail Pharmacy, Pharmacy Benefit Management and Prior Authorization for Commercial HMO/PPO, Medi-Cal and Medicare Health Plans
  • Compliant with HIPPA. Preserving patient confidentiality as defined by state, federal and company regulations

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Resume Overview

School Attended
  • San Jose State University
Job Titles Held:
  • Prior Authorization Pharmacy Coordinator
  • Senior Pharmacy Technician
  • Outpatient Pharmacy Technician
  • B.A.