SUMMARY
Support providers (pharmacists and physicians) with Medicare Part D and/or Commercial pharmacy/ specialty drug benefits analysis, drug coverage inquiries and prior authorizations.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Answer telephones in an efficient and timely manner to lend appropriate assistance to providers
Triage prior authorization requests under the supervision of a Clinical Pharmacist.
Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/specialty claims.
Analyzing written inquiries which lends to entry and updating of pharmacy authorizations into the claims system.
Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.
Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
Assist with internal control systems and regulations compliance.
Perform other related duties as assigned.
EDUCATION AND/OR EXPERIENCE
High School Graduate of GED equivalent required. Two (2) years of college preferred.
Two (2) years experience in retail or hospital Pharmacy required.
Pharmacy Technician Certification (PTCB) preferred
Knowledge of prescription drug names, therapeutic classes and claims processing
Experience with Medicare Part D prescription benefits may be preferred for some positions
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER SKILLS AND ABILITIES
Expert knowledge of pharmacy claims processing
Understanding of formularies and utilization management edits
Familiarity with pharmaceutical manufacturers and product/cost information
Computer Literate (Microsoft Office Products).
Category Sales
Function Clerical / Administrative
Req ID JN -062024-121310