Reports to: Pharmacy Supervisor
Location: 2355 E. Cammelback Dr. Suite 300 Phoenix, AZ 85016
Performs case processing, clinical evaluation and completion of coverage determinations from receipt to adjudication. Utilizes clinical knowledge and resources to evaluate and assess the clinical necessity of the coverage determination. Technician assignments will be broad in nature across DER, Injectables, Appeals and/or Direct Member Reimbursement (DMR).
Additional Responsibilities: Candidate Education:
- Reviews medical records against prior authorization criteria and decision tools and recommends a coverage determination decision on approvals and/or denials on various drug products.
- Verifies eligibility, timeliness and record completeness of coverage determination cases and follows up with the provider as necessary
- Communicates with Pharmacists and Medical Directors, providing updates on the case disposition of coverage determinations.
- Researches and documents the clinical aspects of the case and the reasoning for the coverage determination outcome in numerous databases.
- When appropriate, seeks additional clinical advice and recommendations to properly adjudicate the coverage determination case.
- Electronically enters claim detail information in internal organization applications, PBM applications and documents receipt, disposition and other noteworthy aspects of the cases in these applications.
- Initiates and continues direct communication with health care providers (Pharmacist, Physicians, and Nurses) involved with the care of the member to obtain complete and accurate information for coverage determination.
- Ensures timely processing and review of coverage determinations to meet departmental goals and state/federal specific benchmarks for timeliness.
- Documents data input and output accurately to ensure compliance with data integrity for CMS Universes and corporate compliance directives.
- Ensures that services provided to eligible members are within benefit plan and appropriate medications are being utilized. (i.e.: determining if medication Part D eligible and the 4 brand limit.)
- Assists with implementation of healthcare initiatives and specific strategies that improve the quality and outcomes of care in market.
- Responds to requests from member service and other issues.
- Performs additional projects as assigned.
- Required A High School or GED
- Required 1 year of experience in pharmacy operations managed care, hospitals and/or retail environments
- Preferred 1 year of experience in managed care pharmacy and/or appeals/grievances
Licenses and Certifications:
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to work independently
- Beginner Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Other Ability to use pharmaceutical references
- Beginner Other Ability to evaluate information from both oral and written sources, pharmaceutical references and report information to pharmacists
- Intermediate Other Working knowledge of prescription medications and pharmacotherapy
A license in one of the following is required:
- Preferred Certified Pharmacy Technician (CPhT)
- Required Intermediate Microsoft Word Knowledge of Microsoft Office including Word, Excel and Power Point
- Required Intermediate Microsoft Excel Capable of learning to use Sidewinder, Crystal and WHI Data bases
- Required Intermediate Microsoft Outlook
- Required Beginner Healthcare Management Systems (Generic)