Job Summary

This position supports the Pharmacy Department in processing pharmacy prior authorization (PA) requests in an accurate and timely manner. Clinical decision making is performed using approved guidelines. Supports the internal and external customers of the Health Plan including members, providers, contracted pharmacies, case managers, medical prior authorization staff, and the customer care staff by addressing issues pertaining to pharmacy and providing pharmacy data as requested. Performs ad hoc reporting on pharmacy claims data as requested. Responsible for performing activities and functions in accordance with policies and procedures under the immediate supervision of a pharmacy technician supervisor, a pharmacist, and/or medical director.

Essential Functions

• Processes and finalizes PA requests based on approved guidelines under the supervision of a pharmacist and/or a medical director: entering of PAs into the system and prioritizing requests; checking formulary alternatives, reviewing tried and failed medications; utilizing drug references and verifying the drug being requested is indicated/approved for the condition; documenting all related information regarding the PA approval or non-approval; monitors pending pharmacy prior authorization requests for compliance with regulatory timelines and contacts providers for requested information to avoid out of compliance decisions; respects and maintains highly confidential information as required by HIPAA.

• Understands the formulary, member cost-sharing, and regulatory requirements, both AHCCCS and Medicare. Assures that pharmacy claims are adjudicating correctly. Maintains compliance with all regulatory requirements.

• Communicates clearly and accurately with other healthcare professionals including internal personnel as well as individuals external to the organization. Assists internal and external customers with any pharmacy issues, investigates potential causes, and works to resolve issues in an efficient, comprehensive manner. Interacts with the pharmacy benefits management company to resolve any processing errors or system issues.

• Provides reporting for internal and external customers including, but not limited to, member pharmacy claims history, CSPMP profiles, and pharmacy claims analysis.

• Participates in the daily review of the Medicare denied claims report. Analyzes the reason for the denied claim and works with the pharmacy to resolve any processing issues. Outreaches to prescriber for prior authorization if indicated.

• Participates in regulatory oversight including, but not limited to, audits, operational reviews, or ad hoc data requests.

• Meets established departmental performance metrics for quality and productivity.

Minimum Qualifications

Requires pharmacy technician licensure in the state of practice (where applicable). Pharmacy technician certification required.

Must demonstrate 3 or more years of experience performing pharmacy technician duties in a pharmacy setting with managed care emphasis preferably within a healthcare organization or retail pharmacy. Must have good written and verbal communication skills for interfacing with all levels of staff, physicians, patients and other contacts. Must have the ability to learn and master various software programs necessary for job functions

Preferred Qualifications

Knowledge of medication management information system software and automated dispensing systems. Previous experience with Medicare, Medicaid or Long Term Care preferred

Additional related education and/or experience preferred.