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.
1. Answer telephones in an efficient and timely manner to lend appropriate assistance to providers
2. Triage prior authorization requests under the supervision of a Clinical Pharmacist.
3. Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy / specialty
claims.
4. Analyzing written inquiries which lends to entry and updating of pharmacy authorizations into the claims
system.
5. Communicate coverage determination status to physicians and / or members and effectuate such decisions
within the authorization tool.
6. Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
7. Assist with internal control systems and regulations compliance.
8. Perform other related duties as assigned.
EDUCATION AND / OR EXPERIENCE
1. High School Graduate of GED equivalent required. Two (2) years of college preferred.
2. Two (2) years experience in retail or hospital Pharmacy required.
3. Pharmacy Technician Certification (PTCB) preferred
4. Knowledge of prescription drug names, therapeutic classes and claims processing
5. 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
1. Expert knowledge of pharmacy claims processing
2. Understanding of formularies and utilization management edits
3. Familiarity with pharmaceutical manufacturers and product / cost information
4. Computer Literate (Microsoft Office Products).
ADDITIONAL INFORMATION : The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.
They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
This job description does not constitute a contract for employment.
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