Job ID: J122997
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 14, 2018
I. GENERAL OVERVIEW:
The Pharmacy Coordinator 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. This position 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. Will interact 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.
II. ESSENTIAL RESPONSIBILITIES:
1. Communicate effectively
2. Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department to include but not limited to:
3. Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override
4. Document all authorizations and denials completely and accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member
5. Complete other assigned duties as specified
6. Serve as a resource for technical staff
7. Other duties as assigned or requested.
Knowledge, Skills and Abilities
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No □ Yes □
If yes, indicate the number of direct reports:
V. WORK ENVIRONMENT
Is Travel Required?
No x Yes □
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