POSITION SUMMARY
Assists internal staff, contracted physicians and pharmacists in resolving issues pertaining to the delivery of pharmacy services and processing of prior authorization request for plan members. Interfacing with internal and external customers and pharmacy benefits manager (PBM) to resolve issues that may arise in the provision of pharmacy services and with any utilization management tools that are in effect. Assists in the monitoring and oversight of core department activities.
COMPLIANCE WITH REGULATIONS
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations and accrediting bodies.
RESPONSIBILITIES
- Interfaces with CHG's Customer Service Department, PBM and providers and pharmacies to ensure the provision of Plan's pharmacy benefits and services in accordance with plan documents and standards.
- Assists CHG's Customer Service Department, pharmacies, physicians, case managers, and PBM in addressing members' medication-related needs on a case by case basis.
- Interfaces with PBM in the prior authorization process; processes all prior authorization requests in established timeframes; gathers appropriate clinical information necessary; forwards requests to appropriate clinical reviewers; maintains all records according to established standards.
- Participates in HEDIS-related activities and initiatives and in disease management and outcome studies as required.
- Assists in the preparation of reports by collecting and documenting information and provides written reports to pharmacy management.
- Monitors and documents core department activities according to internal procedures and reports any concerns without delay.
- Maintains customer confidence and protects operations by keeping information confidential.
- Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
- Contributes to the team effort by accomplishing related results as needed.
- Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
- Other duties as assigned.
- Valid Pharmacy Tech license.
EDUCATION
- High school diploma or GED and vocational/specialized training.
- Valid Pharmacy Tech license.
EXPERIENCE/ SKILLS
- Two years' experience in retail pharmacy.
- Minimum two years' experience in managed care pharmacy or pharmacy benefits management.
- Bilingual English/Spanish highly preferred.
- Ability to operate a personal computer, fax, photocopier, calculator.
- Knowledge of word processing and spreadsheets required.
- Strong verbal, written, analytical and interpersonal skills.
- Ability to organize and prioritize work effectively; detail oriented; apply established policies procedures and guidelines for problem-solving and decision making.
- Self-directed.
PHYSICAL REQUIREMENTS
- Prolonged periods of sitting.
- Prolonged use of computer (exposure to CRT and use of keyboard).
- May be required to work evenings, weekends, and holidays.
The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.