Pharmacy Authorization Technician
AlohaCare - Honolulu, HI

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Facilitates all aspects of the Coverage Management / Prior Authorization process, manages the pharmacy/provider services help desk, and assist Customer Service on drug-related concerns/issues for the AlohaCare QUEST (Q), QUEST-Net (QN), Quest-ACE (QA), Advantage (ACA), and Advantage Plus (ACAP) Plans.

Primary Duties and Responsibilities:
  • Review coverage review / prior authorization request
  • Verify appropriate information is completed on request
  • Memo member module acknowledging receipt and status of coverage review requests
  • Forward coverage review / prior authorization requests to designated nurse to determine if the member’s clinical condition/situation warrants an exception
  • Enter required information in coverage management tool for tracking, letter generation, and reporting purposes
  • Enter coverage approvals into Pharmacy Benefit Manager (PBM) system
  • Fax coverage review outcome (authorization approval or denial letter) to Provider and mail associated member denial letter, when appropriate
  • Contact dispensing pharmacy on a case-by-case bases regarding coverage status
  • File coverage review materials in member file
  • Ensure coverage review turnaround times required by State and Federal agencies are adhered to by clinical professional decision-makers
  • Track incoming calls by Plan
  • Review member reimbursement requests, which include verification of member eligibility, plan/formulary coverage, and completion of reimbursement form, if appropriate
  • Speak to members regarding reimbursement requests as needed
  • Verify pharmacy provider participation in AlohaCare’s various pharmacy networks
  • Direct pharmacy to PBM for contracting purposes
  • Verify member eligibility for pharmacies
  • Advise pharmacies of billing procedures and requirements
  • Assist pharmacies with claims processing issues and rejections
  • Complete drug benefit inquiry form and forward to designated nurse to determine if an override is clinically indicated
  • Enter approved overrides into PBM system and contact pharmacy to reprocess the pharmacy claim
  • Assist Pharmacy Liaison/PBM Specialist with the eligibility review of pharmacy universal claim forms and submission to PBM or AlohaCare Claims, whichever is appropriate, for processing
Required Competencies and Qualifications:
  • High school degree required
  • Excellent written and verbal communication skills required
  • Customer service oriented
  • Ability to work in a fast paced managed care environment
  • Train and update designated back-up prior authorization technician(s) on standard operating procedures
  • Back-up to retrieval and submission of weekly Plan Finder Drug files to the Centers for Medicare & Medicaid Services
  • Assist Pharmacy Liaison/PBM Specialist with the updates to the Pharmacy Manager as needed
  • Enter Pharmacy and Provider “lock-in” into PBM system as requested by Case Management
  • Pull pharmacy reports quarterly or as needed
  • Interface with PBM as needed
  • Interface with various other AlohaCare departments as needed
  • Other duties as determined by the Pharmacy Manager and/or Administrator
Preferred Competencies and Qualifications:
  • Pharmacy Technician certification or pharmacy work knowledge preferred
  • Excellent computer skills preferred
An Equal Opportunity Employer

AlohaCare - 14 months ago - save job - block
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