- Independently coordinates and processes pharmacy prior authorizations (PA) taking into consideration pharmacy benefits, medication utilization policies, information submitted by prescriber accurately and in a timely manner and in accordance with departmental policy and procedures.
- Triage, document and prioritize incoming calls and requests while following established protocols Utilize plans reporting capabilities to collect and analyze claims and drug utilization data.
- Interacts with internal plan departments to address pharmacy related issues.
- Researches pended claims and authorizations and corrects issues when applicable.
- Responds to inquiries from physicians, members, and pharmacies related to formulary and prescription benefits.
- Audits processed pharmacy claims to ensure appropriate adjudication while verifying compliance with benefit design and regulatory requirements for all lines of business.
- Demonstrates proficiency in all pharmacy claims systems.
- Collaborates with Plans contracted PBM in regards to PAs, overrides, and issue resolution.
- Conducts outbound calls to resolve prescription issues pertaining to prescription coverage, claim rejections, etc.
- Ensures all member information is kept confidential according to HIPAA regulations.
- Conducts quality assurance measures as assigned.
- Participates in onboarding and training activities of new employees.
- Other duties as assigned by Vice President, Pharmacy or Supervisor.
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
- Valid Certified Pharmacy Technician Rhode Island license
- Minimum of three (3) years experience working in Pharmacy, Pharmacy administration or Pharmacy claims processing
- Independent in problem solving and task management
- Strong Computer Skills (Microsoft Outlook, Excel, Word) and related/integrated systems
- Ability to manage multiple tasks and deadlines
- Strong verbal communication skills
- Valid Certified Pharmacy Technician II Rhode Island license
- Knowledge of Managed Care Plans and/or PBM experience
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Description
Job Details Job Location Smithfield, RI - Smithfield, RI Position Type Full Time Education Level High School or GED Travel Percentage None Job Shift Daytime Job Category Some Experience DescriptionUnder the direct supervision of the Pharmacy Technician Supervisor, the Pharmacy Technician will perform various, assigned administrative operational functions within the Pharmacy department. This position is directly involved with day-to-day operations of the department and is responsible for conducting and coordinating multiple facets of the prescription drug prior authorization (PA) process. The duties associated with this position include PA order entry, updating PAs within the pharmacy claims system, tracking and reporting PA activity and processing PA notifications to members and providers. The position requires a working knowledge and familiarity with prescription drugs. The position works closely with Neighborhoods Medical Management, Grievance & Appeals Unit, claims department, vendors, and Member and Provider service teams. The position requires excellent verbal communication skills and a demonstrated ability to work in an organized, timely, efficient and thorough manner.
Duties and Responsibilities:
Responsibilities include, but are not limited to the following:
Required:
Preferred:
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
