Job type full-time
Full job description
Under the direct supervision of the senior manager of regulatory and pharmacy operations, the pharmacy technician will perform various, assigned administrative operational functions within the pharmacy departmentThis position is directly involved with day-to-day operations of the department and is responsible for conducting and coordinating multiple facets of the prescription drug prior authorization (pa) processThe duties associated with this position include pa order entry, updating pas within the pharmacy claims system, tracking and reporting pa activity and processing pa notifications to members and providersThe position requires a working knowledge and familiarity with prescription drugsThe position works closely with neighborhoods medical management, grievance & appeals unit, claims department, vendors, and member and provider service teamsThe position requires excellent verbal communication skills and a demonstrated ability to work in an organized, timely, efficient and thorough manner.
Duties and responsibilities:
Responsibilities include, but are not limited to the following:
Independently coordinates and processes pharmacy prior authorizations (pa) taking into consideration pharmacy benefits, medication utilization policies, information submitted by prescriber accurately and in a timely manner and in accordance with departmental policy and procedures.
Triage, document and prioritize incoming calls and requests while following established protocols utilize plans reporting capabilities to collect and analyze claims and drug utilization data.
Interacts with internal plan departments to address pharmacy related issues.
Researches pended claims and authorizations and corrects issues when applicable.
Responds to inquiries from physicians, members, and pharmacies related to formulary and prescription benefits.
Audits processed pharmacy claims to ensure appropriate adjudication while verifying compliance with benefit design and regulatory requirements for all lines of business.
Demonstrates proficiency in all pharmacy claims systems.
Collaborates with plans contracted pbm in regards to pas, overrides, and issue resolution.
Conducts outbound calls to resolve prescription issues pertaining to prescription coverage, claim rejections, etc.
Ensures all member information is kept confidential according to hipaa regulations.
Conducts quality assurance measures as assigned.
Participates in onboarding and training activities of new employees.
Other duties as assigned by vice president, pharmacy or senior manager of regulatory and pharmacy operations.
Corporate compliance responsibility - as an essential function, responsible for complying with neighborhoods corporate compliance program, standards of business conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the companyThis position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
Valid certified pharmacy technician rhode island license
Minimum of three (3) years experience working in pharmacy, pharmacy administration or pharmacy claims processing
Independent in problem solving and task management
Strong computer skills (microsoft outlook, excel, word) and related/integrated systems
Ability to manage multiple tasks and deadlines
Strong verbal communication skills
Valid certified pharmacy technician ii rhode island license
Knowledge of managed care plans and/or pbm experience
Core company-wide competencies:
Respect others & value diversity
Analyze issues & solve problems
Drive for customer success
Manage performance, productivity & results
Develop flexibility & achieve change
Job specific competencies:
Build relationships & cultivate networks
Collaborate & foster teamwork
Attend to detail & improve quality
Exercise sound judgement & decision making
Fdr oversight: n/a
Flexible work arrangement:
Yes as approved by management
Yes as approved by management
Neighborhood health plan of rhode island is an equal opportunity employerAll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.