Support BCBSM providers (pharmacists and physicians) with Medicare Part D and Commercial pharmacy drug benefits analysis, drug coverage inquiries and prior authorizations.
Answer telephones in an efficient and timely manner to lend appropriate assistance to providers
Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy claims.
Analyzing written inquiries which lends to entry and updating of pharmacy authorization into the pharmacy claims system.
Analyzes prior authorization data and membership files shared with contracted pharmacy benefit management companies.
Communicate coverage determination status to physicians; members contracted Pharmacy Benefit Manager and pharmacy staff.
Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
Medication management support which may include administrative and technical support tasks for Pharmacy Administration (special research projects), and processing.
Assists in quality analyses, which support the on-going performance monitoring of the pharmacy prior authorization process.
Prepare standard ad-hoc reports using internal pharmacy benefit managers inquiry and report tools.
Assist with internal control systems and regulations compliance.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, protected veteran status or status as an individual with a disability.
- High School Graduate of GED equivalent required. Two (2) years of college preferred.
- Two (2) years experience in retail Pharmacy required.
- Pharmacy Technician Certification (PTCB) preferred
- Knowledge of prescription drug names, therapeutic classes and claims processing
- Experience with Medicare Part D prescription benefits.
- Expert knowledge of pharmacy claims processing
- Understanding of formularies and utilization management edits
- Familiarity with pharmaceutical manufacturers and product/cost information
Blue Cross Blue Shield of Michigan - 5 months ago