This position supports the corporate pharmacists; coordinates and administers the effective and efficient processing of the pharmacy benefits prior authorization process; ensuring that pharmacy benefits are administered in accordance with all regulatory agency requirements.
Primary Job Duties:
- Makes medical necessity approval determinations related to the pharmacy benefit and medical benefit for injectable medications administered in a physicians office based on criteria review, medical policy, contractual provisions, physician chart notes, x-ray reports, lab results and other pertinent data supplied by the physician's office.
- Makes first level medical necessity denial determinations related to the pharmacy benefit and medical benefit for injectable medications administered in a physician's office based on criteria review, medical policy contractual provisions, physician chart notes, x-ray reports, lab results, case studies and other pertinent data supplied by the physician's office. Prepares denial determination with a clinical case summary and escalates the denial to a staff pharmacist and/or medical director for second level review and final determination.
- Researches prescription drug indications, dosage, administration route, contraindications and other pertinent FDA (Food and Drug Administration) information as related to a case, through approved internet sites and/or internal resources.
- Researches and prepares first level summary on case studies for non FDA approved indications for the Pharmacists and or Medical Director, when presented with an off label use case in which a physician is citing off label use studies.
- The incumbent develops and maintains an extensive knowledge base concerning the clinical and technical knowledge necessary to apply medical policies, including technical knowledge related to all FACETS applications and Pharmacy Vendor applications utilized to complete the prior authorization process.
- Interacts with members, physician offices, pharmacies, case managers and pharmacy vendor by responding to clinical questions, obtaining additional medical information, clarifying medical policy and discussing contractual, clinical and regulatory timeframes.
- Serves as company liaison with all departments providing pharmacy and medical injectable related information.
- Maintains current knowledge with respect to all policy and contractual changes.
- Represents Pharmacy Services in audits performed by employer groups including, CMS, NCQA and DOH.
- Supports Claims Queue by researching and responding to routed FACETS Claims. This includes manual pricing calculations as well as final claim resolution instructions for Claims Processing Authorizers.
- Performs timely and accurate case reviews ensuring that regulatory compliance is adhered to.
- Represents HealthNow at group health fairs, open enrollment meetings, Provider manager forums and community fairs as designated by management.
- Trouble shoots and works with other departments, pharmacy vendor, physician office and pharmacies to resolve Customer/Provider Service issues that are beyond the expertise of a Senior Customer Service Representative or Team Leader.
- Supports Provider Inquiry Queue by researching and responding to routed FACETS intakes. This includes authorizing adjustments as well as providing final resolution instructions to Provider Service Representatives.
- Researches and develops written response for New York State Inquiries, Consumer complaints and Subpoenas delegated from Legal.
- Performs other duties as necessary.
Associates Degree (N/A)
- Normal range of hearing
- Excellent time management skills
- Must be able to work in a fast-paced environment with daily work processing deadlines
- Demonstrated customer service orientation
- High degree of business maturity and demonstrated confidentiality
- Knowledge of medical and pharmaceutical terminology
Certified by the Pharmacy Technician Certification Board (PTCB) and a minimum of 2 years experience as a Pharmacy Technician in a hospital, retail or managed care setting.
- Certified Pharmacy Technician
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