Job Description:
The Pharmacy Technician is responsible for answering member, pharmacy, and provider questions as well as researching and resolving problems, to help members understand and optimize the use of their pharmacy benefit. Pharmacy Technicians also work with pharmacists to help review drug coverage requests from members, physicians, and pharmacies to determine medication coverage based on benefit plan design, client specifics, clinical notes, and clinical criteria according to the utilization management system(s).
Required:- High School diploma or equivalent.
- National Pharmacy Technician Certification One year experience in a retail, hospital, managed care, or other similar pharmacy setting.
- Minimum typing speed of 35 words per minute
- Demonstrate working knowledge of direct claims processing, pharmacy computer systems, spreadsheet applications (i.e., Microsoft Excel), phone system and other office/computer equipment as required.
- Knowledge of pharmaceutical generic and trade names.
- Ability to comprehend and follow established office routines, policies, and procedures.
- Effective oral and written communication skills, including grammar and spelling.
- Strong organizational skills, time management and multi-tasking abilities.
- Detail oriented with advanced analytical and problem-solving skills.
- Ability to work effectively as part of a team and independently.
- Provide excellent customer service.
- Follow all plan policies and procedures.
Desired:
Degree in health-related field.
Experience performing medication authorizations in pharmacy or managed care environment.
Responsibilities:
Completes medication coverage requests through prior authorization criteria and escalates requests to Clinical Pharmacists or Medical Directors when requests require clinical review or is not approvable through the automated system.
Contacts providers to obtain all necessary information for coverage requests prior to referring cases to Clinical Pharmacists or Medical Directors.
Attaches relevant policy(ies) for the medication requests to the case documents prior to referring cases to Clinical Pharmacists or Medical Directors.
Identifies and documents the relevant policy information prior to referring cases to a Clinical Pharmacist or Medical Director for review.
Resolves and documents coverage request outcomes in pharmacy benefit manager's system and communicates decision to physician's office and/or members through verbal and/or written notification in accordance with company policies.
Researches, resolves, and documents physician or member inquiries and grievances and documents outcomes in the pharmacy benefit manager's system, medical review system or customer service tool in an accurate and timely manner.
Provides verbal verification of member's plan eligibility and applicable pharmacy benefits.
Utilizes pharmacy benefit manager and medical review system to update, modify and extract member information.
Details members and providers on pharmacy benefit inquiries such as formularies and pharmacy networks.
Assists pharmacies in processing prescription claims; review and troubleshoot claims for accuracy and adherence to contract guidelines.
Consults with clinical pharmacists for guidance and assist if necessary.
Gathers clinical documentation necessary for the performance of medication reconciliation and yearly medication reviews and refers documentation to a Care Management Pharmacist for review.
Identifies and documents peer-to-peer requests and refers cases to a Clinical Pharmacist or Medical Director for review.
Interacts with staff, customer service and supervisors to ensure best practices.
Follows policy and procedures pertaining to all lines of business.
Ensures turnaround times meet requirements with company, state, and federal regulations.
Meets internal key performance indicators as defined in The Health Plan’s Policies and Procedures.
Explains Appeal and Grievance process to members and providers.
Identifies, documents, and sends appeal requests to the Appeals and Grievances Department per Appeal and Grievance Department Policies and Procedures. Assists Appeals Coordinator, Clinical Pharmacist and Compliance with pharmacy benefit grievances as needed.
Handles calls and correspondence after hours (when scheduled) regarding pharmacy issues from providers and members. Pharmacy Technicians are responsible for reporting any changes in licensure status (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor throughout their term of employment.
Equal Opportunity Employer:
The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment. TBD 28 hours
