This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.
- Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner.
- Interact with staff to implement processes and problem solves.
- Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department.
- Prioritize requests for drug authorizations or denials.
- Review of prior authorization criteria for drug products.
- Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity.
- Ensure adherence to call center turn around time requirements associated with DPW/CMS regulations.
- Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override.
- Search member claim history profile and recommend formulary alternatives wherever feasible.
- Contact physician network provider to obtain necessary and/or additional information when necessary.
- Consult with staff clinical pharmacist for guidance and assistance as necessary.
- Document all authorizations and denials completely, accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member.
- Populate all authorization and denial information fields within the OnBase information system.
- Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
- Complete other assigned duties as specified.
- Identify and report improper coordination of benefit billing practices through paid clams review.
- Participate as pharmacy representative in onsite member appeals and grievances sessions.
- Serve as a resource for technical staff.
- Other duties as assigned or requested.
- High school diploma or GED
- Experience in pharmacy prescription claims processing/submission/payment.
- Associate degree
- Pharmacy technician certification certificate
- Experience working in a managed care medication formulary management environment
- Working knowledge of retail pharmacy and/or third party prescription procession
- Strong background and understanding of medications and formulary terminology
- Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation
- Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
- Excellent interpersonal, communication and attentive listening skills
- Strong organizational skills, detail oriented
- Demonstrated excellence in communication skills
- Demonstrated ability to work well with others
- Demonstrated ability to work in a fast paced, multi-task environment
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org