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    Pharmacy Services Technician - Boise, ID, United States - Cambia Health Solutions, Inc

    Cambia Health Solutions, Inc
    Cambia Health Solutions, Inc Boise, ID, United States

    6 days ago

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    Description
    Pharmacy Services Technician

    Looking for candidates within Idaho, but the right candidate will be eligible for a remote role within our 4-state footprint (WA, ID, OR, and UT).

    Primary Job Purpose

    The Pharmacy Services Technician is a corporate-wide technical support resource for pharmacy benefit, reimbursement, and other drug use issues which do not require clinical judgment.

    This function assists the Clinical Pharmacy Consultants and Pharmacy Services staff with formulary-related operations and other operational processes which require knowledge and experience with pharmaceuticals.

    Normally to be proficient in the competencies listed below:

    Pharmacy Services Technician would have a high school diploma or related certificate and five years of experience as a pharmacy services technician in a retail, hospital, or other licensed pharmacy setting or equivalent combination of education and experience.

    Pharm tech certificate may be substituted for two years of experience.


    Responsibilities:
    Performs all duties as described in this document unless doing so would require clinical judgement.

    In any situation in which clinical judgment is necessary, the Pharmacy Services Technician will seek assistance from appropriate medical personnel.

    Appropriate medical personnel will be available for support during normal business hours.

    Responds to non-clinical pharmacy issues from providers, pharmacy services staff, case managers, preauthorization nurses, ENCC personnel, and government programs personnel and customer service.

    These pharmacy issues include formulary drug coverage, appeal and reconsideration claim status, and pricing for drug claims.

    Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals.

    Prepares reconsideration requests for Clinical Pharmacy Consultant review by obtaining and organizing appropriate documentation, including, but not limited to medical chart notes/reports and medication profiles.

    Communicates (orally and by written documentation) information and determinations to providers and members as necessary.

    Obtains and organizes drug utilization data, including patient specific and population-based data, in a manner which facilitates clinical review and decisions by Clinical Pharmacist Consultants.

    Organizing data includes but is not limited to sorting drugs into appropriate therapeutic and generic categories.

    Assists with auditing and investigations of medication-related claims, cases, and providers to identify misuse of medications, misuse of (Regence HMO Oregon) resources, substance abuse, and erroneous and fraudulent billing practices.

    Investigates and organizes workflow for claims referred to Pharmacy Services for review and allowable determination (misc. J codes, providers on review, reconsiderations).

    Supports wellness and disease state management programs for Pharmacy Service and corporately which contribute to NCQA accreditation and ongoing quality improvement.

    Contributes to and supports the corporation's quality initiatives through process improvement teams and by encouraging team and individual contributions toward the corporation's quality improvement efforts.


    Minimum Requirements:
    Knowledge of medical terminology, health care coding systems such as ICD-10, CPT and HCPCS and HIPAA regulations.
    Knowledge of pharmaceutical products, including orals, injectables, infusion products, and chemotherapy.
    Knowledge of general office practices and procedures.
    Demonstrated knowledge of grammar and techniques of business practice.

    Ability to interact effectively with a variety of health care professionals, including physicians, nurses, pharmacists, and billing staff both internally and externally.

    Demonstrate maturity, tact, diplomacy, and persuasiveness.
    Demonstrated ability to perform pharmaceutical pricing calculations.
    Ability to type 30 words per minute, 60 wpm preferred.
    Demonstrated ability to operate a variety of standard business machines including calculators, copiers, and faxes.
    Basic computer programs skills (Word, Excel, etc.).
    Ability to organize, plan, and prioritize daily workflow and projects within time constraints.
    Experience with health insurance and/or prescription benefits preferred.


    Work Environment:
    Work primarily performed in an in-home environment.
    May be required to work overtime.
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