Performs reviews of prior approval requests submitted by enrolled providers. Escalates problems to appropriate personnel when needed.
Performing under North Carolina's approved criteria that outlines policies and requirements this position determines prior approval for specific procedures.
Answers incoming provider calls regarding prior approval request processing. Documents prior approval requests and associated history.
Evaluates available information to validate prior approval requests. Verifies policyholder information, policy effective dates, premium status and verification of prior approval request eligibility.
Sends prior approval request form to provider for updating, correction or completion
Investigates simple to moderately complex prior approval request and determines level or resolution if appropriate; advises provider of status; assists in negotiating settlement and resolution of prior approval request.
Identifies need for additional information; contacts appropriate source to obtain needed information.
Performs review of prior approval requests for pharmacy program
Takes escalated calls from team members
Provides training and redirection regarding pharmacy prior approvals and recipient lock-in
Reviews daily and weekly reports to ensure performance metrics are met
Monitors queue to ensure that performance metrics are met
Other duties as assigned
High school diploma or general education degree (GED).
Minimum of one-year pharmacy experience or pharmacy technician training or certification preferred
We are GDIT. The people supporting some of the most complex government, defense, and intelligence projects across the country. We deliver. Bringing the expertise needed to understand and advance critical missions. We transform. Shifting the ways clients invest in, integrate, and innovate technology solutions. We ensure today is safe and tomorrow is smarter. We are there. On the ground, beside our clients, in the lab, and everywhere in between. Offering the technology transformations, strategy, and mission services needed to get the job done.
GDIT is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class.