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About Moda Health

Moda Health, established in Oregon in 1955, is committed to delivering high-quality healthcare coverage and compassionate community support. As a company that embraces diversity and inclusion, Moda values different perspectives that strengthen the organization and encourages applications from candidates who share this commitment.

Position Summary

The RX Prior Authorization Coordinator I is responsible for handling pharmacy prior authorization requests using an electronic PA platform, ensuring compliance with clinical guidelines and health plan benefits. This role involves accurate data entry into claims adjudication systems to facilitate claims processing. This is a full-time remote position.

Key Responsibilities

Precisely enter prior authorization requests into multiple systems and track their status, ensuring adherence to corporate policies and government regulations for timely decisions and communications to members and providers.
Conduct initial assessments and evaluations of PA requests to prepare and determine outcomes by applying established clinical and benefit criteria.
Employ critical decision-making skills to interpret formulary coverages and plan benefits, preparing documentation and directing requests to clinical teams as needed.
Interpret and apply contract documents including evidence of coverage, handbooks, and summary of benefits to inform decisions.
Resolve pharmacy benefit and formulary issues for members across various commercial and ACA plans, evaluating member eligibility and distinguishing among diverse benefit plans according to state regulations.
Screen requests for formulary requirements such as PA necessity, non-formulary exclusions, and quantity limits.
Monitor and ensure pharmacy turnaround times comply with National Committee for Quality Assurance (NCQA) standards.
Identify when additional information is needed from providers and assign these requests appropriately to Rx Assistants.
Communicate PA decisions effectively through electronic, fax, telephone, and email channels to providers, members, pharmacies, and internal departments within required timelines.
Support tracking and documentation for member appeals, grievances, and complaints within necessary deadlines.
Interact with providers and their offices to gather complete and accurate information to process prior authorizations successfully.
Collaborate actively with team members to respond to unit needs and perform other assigned duties.

Work Environment and Interactions

This job is performed in an office setting with prolonged periods of close computer work and frequent phone communications. Remote work requires a reliable high-speed wired internet connection and comfort with virtual meetings requiring on-camera participation.
Working hours may extend beyond the standard workweek, including evenings and occasional weekends, to meet business demands.
The role involves communication internally with clinical teams, operations, customer service, appeals, healthcare services, marketing, and Medicare programs, and externally with members, PBM vendors, providers, pharmacists, and pharmacies.

Required Qualifications

High school diploma or equivalent is mandatory; a college degree is preferred. Equivalent healthcare or pharmacy experience may substitute for educational requirements.
At least one year of experience in a prior authorization or pharmacy technician role within a pharmacy or health plan.
External candidates must hold a valid State Pharmacy Technician license; internal candidates must obtain one within six months of hire. Certification as a Pharmacy Technician (CPhT) is preferred but not required.
Strong critical thinking skills with the ability to interpret benefit contracts, clinical standards, and internal policies.
Proficient understanding of medical and pharmaceutical terminology and computer applications, including Microsoft Word and Excel. Willingness to learn additional third-party PBM claims adjudication systems.
Ability to navigate Moda's internal software and electronic PA systems effectively.
Typing speed of at least 40 words per minute.
Flexibility to work necessary hours to complete assigned tasks successfully.
Capability to multitask, maintain quality and productivity standards, handle confidential information professionally, adapt to changing environments, manage stress, and project a professional demeanor.
Excellent analytical, problem-solving, organizational, and decision-making skills.
Strong interpersonal communication skills including active listening, team collaboration, and respectful communication with co-workers and members.
Comfort working in a fast-paced, production-focused environment.
Ability to professionally manage and resolve pharmacy-related conflicts.
Consistent punctuality and reliable daily attendance.

Compensation and Benefits

Hourly pay ranging from $21.30 to $23.96, depending on experience and qualifications. Applicants meeting only minimum qualifications will be eligible for the lower end of this range.
Comprehensive benefits including medical, dental, vision, pharmacy coverage, life insurance, and disability benefits.
401K with company matching contributions.
Flexible Spending Account (FSA).
Employee Assistance Program.
Paid time off (PTO) and company-observed holidays.

Diversity and Inclusion

Moda Health is dedicated to providing equal employment opportunities without discrimination based on race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other protected classification. This policy extends across all employment terms including recruitment, hiring, placement, promotion, termination, recall, transfer, leave of absence, compensation, and training. For accommodation inquiries, candidates can contact Moda's human resources team.

RX Prior Authorization Coordinator I