Prior Authorization Assistant - Pharmacy

📋 Description

• • Ascertain is at the forefront of revolutionizing healthcare administration by developing advanced AI agents designed to automate the burdensome tasks that often overwhelm care teams. Our innovative solutions are already deployed within major health systems and large specialty groups, demonstrably saving hundreds of staff hours weekly and enhancing operational efficiency. We are backed by prominent organizations such as Northwell Health, New York’s largest health system, and Deerfield Management, a leading healthcare investment firm. Our collective mission is to restore valuable time, foster trust, and enable healthcare professionals to focus on what matters most: patient care. The urgency of our work stems not from typical startup pressures, but from the critical need of our customers to achieve financial resilience and operational clarity in an increasingly strained healthcare system.
• • This role is a hands-on position for an individual who excels in high-volume operational settings and possesses the ability to balance significant individual contributions with robust team support. Initially, you will be directly responsible for processing prior authorizations, often managing a substantial caseload. Concurrently, you will serve as a key point of contact and a reliable resource for your fellow Ascertain Assistants, sharing your expertise and assisting them in navigating complex cases. As Ascertain’s platform evolves and workflows become increasingly automated and integrated with our AI capabilities, this position is designed to transition into a hybrid role encompassing both operational responsibilities and technological engagement. This is a departure from traditional, shift-based healthcare roles; it is an outcome-driven position that highly values initiative, sound judgment, and unwavering follow-through.
• • As a Prior Authorization Assistant at Ascertain, you will be instrumental in the success of our novel AI-powered prior authorization solution. You will engage directly with Ascertain leadership and product development teams, providing invaluable insights that will shape the future of prior authorization processes through the application of artificial intelligence. This presents a unique and exciting opportunity to operate at the critical intersection of healthcare operations and cutting-edge technology. Your responsibilities will involve close collaboration with healthcare providers to alleviate administrative burdens and optimize intricate workflows. On a daily basis, this includes the meticulous manual processing of authorizations and the oversight of automated submissions for a wide range of services, including office visit referrals, complex procedures, and pharmaceutical approvals.
• • Key responsibilities include:
• • **Prior Authorization Processing:** Accurately review and verify insurance information, patient eligibility, and prescription details to initiate and process prior authorization requests for medications.
• • **Payer and PBM Engagement:** Work directly with a variety of insurance payers, Pharmacy Benefit Managers (PBMs), and specific pharmacy benefit plans, demonstrating a deep understanding of their unique requirements and processes.
• • **Policy Interpretation:** Interpret complex formulary guidelines, step therapy protocols, quantity limitations, and other coverage criteria to ensure compliance and facilitate approvals.
• • **Provider Collaboration:** Communicate effectively with healthcare providers, including physicians, nurses, and administrative staff, to gather all necessary medical documentation, clinical notes, and supporting information required for authorization.
• • **Status Monitoring and Tracking:** Diligently monitor and track the status of all authorization requests from submission to resolution, ensuring timely processing and proactive management of any delays or issues.
• • **Inquiry Response:** Serve as a primary point of contact for inquiries from healthcare providers, patients, and insurance companies regarding the status of authorization requests, providing clear and timely updates.
• • **Record Maintenance:** Maintain precise and organized records of all authorization requests, including approvals, denials, and any associated documentation, ensuring data integrity.
• • **Internal Collaboration and Process Improvement:** Partner with internal Ascertain teams, including product, engineering, and customer success, to troubleshoot authorization issues, identify bottlenecks, and contribute to the continuous improvement of our operational processes and platform functionality.
• • **Regulatory and Industry Awareness:** Stay abreast of evolving insurance policies, regulatory changes, and emerging industry trends specifically related to prior authorizations and pharmaceutical benefits to ensure best practices are followed.