High school diploma plus one to three years experience in retail pharmacy setting or in prescription benefit management. Certified Pharmacy Technician license preferred. Demonstrated ability to communicate effectively with pharmacies, physicians, physician offices and other providers. Requires good organizational skills, ability to retain plan benefit details, basic medical terminology, and broad knowledge of current pharmaceutical products.
Primary Job Functions
Respond to incoming Automatic Call Distribution (ACD) calls to meet quality standards and performance measures.
Enters pharmacy prior authorizations directly into system for prescription adjudication, using correct medication NDC numbers.
Functions as a liaison between Provider Services and Customer Service, Marketing, and Enrollment. Works with departments to identify and resolve complex provider inquiries, research overrides and reject codes, and other adjudication issues.
Prepares non-formulary prior authorization requests, using eligibility, benefit riders, and medication histories.
Approve prior authorization requests using established criteria or pend to the pharmacist for review when appropriate.
Prepares letters for mailing to primary care physician, patient, and pharmacy.
Attend continuing education programs to update knowledge base of current pharmaceutical products, practices, and trends.
Responsible for identifying and tracking NDC numbers on the formulary not on the Auxiliary files.
Works directly with the Pharmacy Benefit manager to serve pharmacies and medical staff. Educates provider offices and pharmacies on pharmacy prior authorization process, non-formulary drug authorizations, and how to read our formulary.
Performs other functions as required.
Presbyterian Healthcare Services - 2 years ago