Job Description : Job Summary :
This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and / or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects.
Must maintain performance in compliance with organizational or department goals and in compliance with regulatory agencies
Responsibilities :
Process prior authorizations received via prior authorization help line, by evaluating the medical necessity / appropriateness for specific drugs and based on medical criteria.
- Directly interact with members physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues.
- Conduct intervention with physician & pharmacy office staff to facilitate formulary compliance and generic dispensing.
- Process appeals complaints executive inquiries and compliance related issues.
- Provide recommendations to increase efficiency, accuracy and productivity in the department.
- Process ad hoc request for information or reports from stakeholders.
- Participate in client member and employee training to ensure practical understanding of pharmacy services programs and operations.
- Assist in the day to day business functions of the pharmacy department as well as the Medication Therapy Management program.
- Provide support to various clinical programs within the pharmacy department.
Education / Experience :
- Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration.
- Requires minimum of two (2) years experience in third party prescription program claim adjudication.
- Requires minimum of two (2) years experience as a Pharmacy Utilization Management Specialist.
- Requires prior customer service / service quality initiative experience.
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