Pharmacy Internal Monitor (Medicare)

Job Description

Job Summary

Molina Pharmacy Services / Management staff work to ensure that Molina Medicare members have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner.

These jobs are responsible for creating, operating, and monitoring Molina Health Plan’s pharmacy benefit programs in accordance with all federal and state laws.

Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug / provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics with regard to patient outcomes, medications safety and medication use policies).

Job Duties

• Performs monthly quality monitoring of pharmacy requests and phone calls.
• Provides coaching to technicians and representatives under direction of the supervisor.
• Reviews Medicare pharmacy technician work for accuracy to ensure compliance with Medicare regulations in regards to coverage determinations, formulary exceptions and appeals.
• Assists management by preparing and analyzing compliance / audit reports.
• Reviews transition reports and ensures letters are being mailed within CMS defined timelines.
• Investigates claim issues daily based on the Daily Reject Report and reports any inappropriate denials to the supervisor / director.
• Reviews prior authorization requests on an as needed basis.
• Answers phone calls from members, pharmacies and providers when the call center needs assistance.
• Develops training materials and trains new hires as required.
• Assists in the development and implementation of internal processes, policies and procedures.
• Prepares, researches and validates information for both internal and external program audits.

Job Qualifications

REQUIRED EDUCATION :

Associate’s Degree or equivalent experience

REQUIRED EXPERIENCE / KNOWLEDGE, SKILLS & ABILITIES :

• 3 years’ experience as a Pharmacy Technician or 2 years’ experience in Medicare managed care utilization management
• Ability to organize work, set priorities, meet critical deadlines and manage multiple projects
• Detail oriented and organized
• Demonstrates the ability to cooperate with a variety of people and achieve results
• Strong process related analytical skills
• Excellent verbal and written communication skills
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION :

Active and unrestricted State Pharmacy Technician license

PREFERRED EDUCATION :

Bachelor’s Degree or equivalent experience

PREFERRED EXPERIENCE :

Knowledge of Pharmacy Benefits Management methodologies.

To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.

Pay Range : $20.29 - $31.97 / HOURLY

Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance.

If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission.

Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.

Job Type : Full Time Posting Date : 11 / 07 / 2024