Clinical Authorization and Appeals Specialist
PANTHERx Rare Pharmacy
Summary
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.
Job description
Purpose
The Clinical Authorization and Appeals Specialist provides support and education to health care providers for prescribed treatment therapies. This role serves as a single point of contact for health care providers to coordinate alignment of documentation with prior authorization and appeals criteria. This role submits timely prior authorizations requests, appeals, initiatives to increase patient adherence, and closes collaboration with both internal and external stakeholders.
Responsibilities
- Educates health care providers regarding prior authorization and appeals criteria for prescribed therapies.
- Assesses clinical documentation provided and assist the health care provider with alignment to specific plan criteria.
- Creates initiatives to increase patient adherence and optimize patient care.
- Possess a broad and deep understanding of assigned disease states, products, and clinical programs.
- Closes collaboration with program team members as well as external stakeholders.
- Performs appropriate and accurate documentation of cases using call management software.
- Demonstrates appropriate judgment skills to be able to make independent clinical decisions.
- Fosters teamwork by trusting and supporting each other while encouraging collaboration at all levels of the organization.
- Provides superior customer service to internal and external clients, customers, and patients.
- Assumes accountability for own professional practice in achieving patient outcomes.
- Completes all other duties as assigned.
Required Qualifications
- Associate degree or bachelor's degree from an accredited nursing school as a Registered Nurse (RN).
- Must have demonstrated competence in community health or patient care setting, providing direct patient care with patients for 1-3 years.
- Strong writing and grammar skills.
- Strong organizational skills and a thorough knowledge of computers (Microsoft Office and Windows) are required.
- Demonstrated ability to work independently and meet goals.
Preferred Qualifications
- 1-3 years of specialty pharmacy experience
Requirements
- Associate degree or bachelor's degree from an accredited nursing school as a Registered Nurse (RN)
- Demonstrated competence in community health or patient care setting, providing direct patient care for 1-3 years
- Strong writing and grammar skills
- Strong organizational skills and thorough knowledge of computers (Microsoft Office and Windows)
- Demonstrated ability to work independently and meet goals
- 1-3 years of specialty pharmacy experience (preferred)
Benefits
- Medical, Dental & Vision
- Health Savings Account
- Flexible Spending Account
- 401(k) Matching
- Employer-Paid Life Insurance
- Short-Term Disability
- Long-Term Disability
- Employee Assistance Program
- Paid Time Off
- Paid Holidays
- Hybrid Work Schedules
Company overview
PANTHERx Rare Pharmacy is a leading specialty pharmacy exclusively focused on rare and orphan diseases, established in 2011 and headquartered in Pittsburgh, Pennsylvania. Known as The Rare Disease Pharmacy®, the company has grown to become the largest independent rare pharmacy in the United States, licensed in all 50 states and U.S. territories. PANTHERx specializes in distributing orphan products and providing comprehensive access and support services for patients with rare conditions, transforming lives by delivering medical breakthroughs, clinical excellence, and personalized care solutions. The company operates with a hyper-personalized approach, developing deep relationships with patients, healthcare professionals, and pharmaceutical partners while maintaining small-company responsiveness despite its established resources. PANTHERx holds dual accreditations in rare disease from the Accreditation Commission for Health Care (ACHC) and Utilization Review Accreditation Commission (URAC), and has been recognized as an eight-time winner of the prestigious MMIT Patient Choice Award for patient satisfaction. With over 7,000 rare diseases identified affecting 25-30 million Americans, PANTHERx plays a critical role in addressing the significant unmet needs in the rare disease community through innovative pharmacy services and patient-centered care models.