Job ID: J135231
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 23, 2019
This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. The incumbent will evaluate member profiles and claims histories. Conducts telephonic outreach to the Gateway Health member population and providers. Responds to provider and member inquiries concerning medication adherence or gap closure. Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing coordination of benefits practices/procedures.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
SummaryThis 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. Clearly defines the medical necessity of non-formulary and prior authorization medication exception requests, by reviewing member claims history,. 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.
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