- Manage the entire prior authorization process for Spravato and other specialty medications in a behavioral health setting.
- Conduct insurance eligibility and benefits verification prior to patient treatment.
- Review patient insurance coverage, network status, deductibles, copays, and authorization requirements.
- Gather and submit required clinical documentation via EHR and authorization platforms (e.g., CoverMyMeds, payer portals).
- Track and follow up on submitted prior authorization requests until final determination.
- Handle denied authorizations by preparing and submitting appeals and coordinating peer-to-peer reviews as necessary.
- Accurately document all authorization activities and maintain detailed records in both EHR and internal systems.
- Provide patients with cost estimates based on verified insurance advantages and coverage.
- Identify correct billing pathways (medical vs. pharmacy benefit) and process authorizations accordingly.
- Work closely with payers, specialty pharmacies, and behavioral health providers to ensure timely and accurate authorizations.
- Maintain compliance with payer-specific authorization requirements, timelines, and state-specific guidelines.
- Utilize tools such as CoverMyMeds, Tebra, Dr. Chrono, and payer portals for efficient workflow management.
- Prioritize and manage multiple cases simultaneously while ensuring high accuracy and attention to detail.