Description: Job Profile Summary
Position Purpose:
The Pharmacy Technician may perform duties in one or more of the following areas: Formulary Management, Pharmacy Audit and Recovery, Pharmacy Service Center, Medicare Part D/Part B, Appeals, Medicare Part D Operations and State Health Programs Pharmacy Operations or Prior Authorization.
Using established company guidelines, the Pharmacy Technician reviews requests made by physicians, medical groups, pharmacies and members for the use of prescription drugs and pharmacy benefits. The technician researches and resolves questions, problems or issues. May consult with Clinical Pharmacists or Regional Medical Director on related issues.
Education/Experience:
High School diploma or GED required. 1 year Pharmacy Technician experience. Customer Service/retail experience preferred
License/Certification: Valid Pharmacy Technician License preferred.
Responsibilities
Formulary Management:
"Reviews and processes formulary change requests from Health Net plans
"Submits and maintains formulary change requests to Health Net s pharmacy claims processor
"Generates, maintains and reviews Formulary Status Grids
"Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance
"Assists Clinical Pharmacist with formulary database maintenance and updates to company web site
Pharmacy Audit and Recovery:
"Performs a variety of assignments required for pharmacy audit and recovery functions
"Reviews paid claims for quantity and/or billing discrepancies. Corresponds with pharmacies as needed to communicate review finding
"Faxes inquiries to pharmacies related to review findings
"Answers in-coming calls and responds appropriately to faxed correspondence from pharmacies
"Updates Access database with incoming phone calls, faxes and e-mails
Pharmacy Services Center:
"Takes member inquiry calls for benefit questions including prior authorization requests
"Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position
"Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request
"Process member submitted claims
Prior Authorization:
"Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim
"Assign, enter and document prior authorizations into appropriate claims processing system
"Answer phone calls for prior authorization inquiries
"Researches and resolves issues using the appropriate reference material
"Responsible for knowing and interpreting pharmacy and medical benefits
Medicare Part D Operations:
"Reviews and processes PDE files
"Researches and resolves issues using the appropriate reference material
"Assists in pharmacy claims corrections projects
"Performs audits and quality checks on active prior authorizations claims
"Assists with identifying and correcting eligibility and group issues
"Processes member claims
State Health programs Pharmacy Operations:
"Liaison to internal and external departments for SHP pharmacy
"Operational issue resolution, including issues from Prior Auth, Appeals and Grievances, and Member/Provider Services
"Preparation and review of various operational reports and audits
"SHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenance
"Maintenance of prior authorization database files
"Medi-Cal DMR processing
"Assist with SHP clinical projects
"Assist with Medi-Cal prior authorizations
Oversight and Audit Support:
"Assists in the implementation of regulatory changes
"Participates in maintaining consistent processes/methods for development, implementation, communication and training on new/updated policies and procedures
"Participates with Business Units/departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into P&Ps that span multiple departments
"Provides support and monitoring to ensure compliance of First Tier, Downstream and Related Entities (FDRs)
"Assists with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)
Appeals:
"Identifies validity of appeal.
"If not a valid appeal, be able to send request to correct department
"Verifies drug, dosage, quantity, provider, diagnosis information
"Research using formularies and prior authorization criteria to verify if additional information is needed.
"If additional information is needed, reach out to providers and members and communicating clearly what information is needed
"Other appeal tasks as assigned
Prior Authorization Medicare Part D and Part B:
"Tracks and triage coverage determination and/or prior authorization requests submitted from providers and determine if a pharmacist review is required
"Obtains verbal authorizations and request detailed clinical information from prescribers
"Approves coverage determination and/or prior authorization requests based on defined criteria
"Enters and documents coverage determination and/or prior authorization request decisions into the PBM system and notify providers and/or members
"Responds to client inquiries regarding authorization approvals and PBM online applications
"Refers coverage determination requests for specialty drugs to delegated vendor or client for processing
"Contacts providers for additional information to facilitate coverage determination reviews
"Notifies physicians, providers, and members of coverage determination request decisions
Performs other duties as assigned
Complies with all policies and standards
Custom Fields:
Name: Which Health Plan, programs or functions will this work support?
Value: *** Pharmacy Services
Name: If this request is replacing a previously canceled request, please provide the original Request ID
Value: None
Name: Field Worker
Value: No
Name: Shortlisting Date
Value: None