Job Description

"**REDUCED Non-Billable Orientation (NBO) Job - 0 Hours NBO vs. Standard 40 NBO**" Pharmacy Tech Role **OR PHARM TECH LIC REQUIRED** **MUST have advanced Excel skills. Do not submit without ADVANCED EXCEL. On call 2-3 weekends per year. This position is responsible for performance of technically detailed pharmacy and benefit work affecting pharmacy and health plan operations, programs and information systems in the Pharmacy Services Department of Healthcare Experience & Operations Division. Position includes integration of technical pharmacy aspects with that of medical review, case management, mental health/chemical dependency, and quality management. Technician responsibilities include communicating directly with Providence Health Plan (PHP) Customer Service and PHP Members, PHP Network Pharmacies, and regulatory entities at the federal and state level. The position also communicates directly with pharmacists, nurses, physicians, and other health care providers and their staffs regarding claims, medication management programs, and initiatives. DUTIES: 1. Excellent member care to find solutions and ease members way during first contact communications. 2. Maintaining excellent customer service to our external partners such as pharmacy network, prescriber, and caregivers to maintain strong relationships throughout all interactions. 3. Functioning as a liaison and problem solver with multiple providers (physicians, pharmacists, office staff, hospital staff, member, and payor), or Plan departments. 4. Identification and response to requests for medical preauthorization which require immediate determination by a Clinical Reviewer or Clinical Pharmacist. 5. Management of multiple priorities and time deadlines efficiently and effectively through ability to work independently while cognizant of team environment and areas that require collaboration. 6. Administration of pharmacy benefits, pharmacy network contracts, and employer group contracts in a manner that achieves PHP's mission, vision, values, and regulatory obligations while meeting the needs of the individual. 7. Understanding of medical drug benefits and channel management (contracted network and policies). Patient Population Served: Neonate, Pediatric, Adolescent, Adult, Geriatric Consequently, the caregiver must be competent in the interpretation of a member's self-report or behavior, and this information must be interpreted with an understanding of the cognitive, physical, emotional/psychosocial and chronological maturation process. The individualized treatment of members will reflect an understanding of their needs and range of necessary care. ESSENTIAL FUNCTIONS: Coordinates and processes independently pharmacy prior authorizations taking into consideration pharmacy benefits, medication utilization policies, documented technician approval criteria, information submitted by prescriber, and age-related presentation of member requesting. Maintains pharmacy benefit member eligibility review process and database. Oversees point-of-service claims transactions processed on a daily basis through our claims processing system. Refers unusual occurrences to business systems analyst. Takes, triages and documents incoming calls and requests, identifies and obtains resource for those requiring immediate attention, handles those appropriate through established protocols utilizing level of assessment and judgment. Routes work to other resources as needed. Performs intake and system data entry of information such as: authorization and referral requests, member demographics, discharge information, medication therapy management, drug utilization management. Uses sound judgment in identifying the need for clinical review or pharmacist/physician intervention by routing to appropriate licensed caregivers based on guidelines and established protocols/procedures. Determines and assigns appropriate and correct coding such as length of service, level of care, diagnosis and procedure, and system identifiers. Identifies medical cases for review by using ICD-10 and CPT-4 coding systems. Provides technical assistance and coding support to Clinical Reviewers by using ICD and CPT coding systems to ensure accurate diagnosis and procedure codes. Initiates information system search for needed documentation and information for cases and their review. Assists in the development and maintenance of loss reports. Notifies prescribers of prior authorization and specific medication utilization issues, including communication of clinical status and documentation of such notification. Acts as department liaison and resource to members, Health Plan providers, and Health Plan departments to problem solve or address inquiries regarding work, workflow, processes, information system issues and relationships. Communicates with members, patients, network pharmacies and providers to obtain information, signatures and appropriate sign off in order to facilitate workflows. Develops written communications to prescribers and network pharmacies as directed. Audits processed pharmacy claims, system call documentation, and written correspondence for quality ensuring information is correct, complete, and clear. Communicates and serves as a resource to Customer Service, marketing staff, provider relations staff, pharmacies, physicians and others. Develops written communications such as frequently asked questions as needed. Trains and assists provider and office staff, members and payors, operations department and other Health Plan employees in pharmacy processes and system usage as applicable. Serves as knowledge holder on pharmacy matters within the health plan and serves as a consultant as needed and within scope of position. Continuously monitors security and safety of medical records and medical information to protect confidentiality. Purges medical and other records as required according to established protocols. Reports statistical information on work unit activity. Collects and analyzes data and develops reports to indicate quality and effectiveness of work. Recommends and initiates change to ensure continuous quality improvement in work processes. Researches pended claims and authorizations or incomplete medical records and provides resolution or recommendations for solution. Authorizes payment of pharmacy claims and DMR's (direct member reimbursements) according to established departmental policies. Collects, organizes, reviews and verifies records submitted by prescribers and network pharmacies knowing that records are subject to both federal and state review and/or audit. Maintains sound working knowledge of all relevant policies and procedures with working knowledge of health plan pharmacy operations specific to duties and healthcare regulations specific to duties. Has an awareness and initiative for training and systems opportunities for continuous quality improvement and alerts a supervisor or trainer of recognized need. Develops written procedures for workflow processes. Education Bachelors Degree or at least 2 years of Experience as a pharmacy technician in a managed care environment. (handling prior authorization review and mandatory audits across all lines of business -Medicare, Medicaid, Commercial Fully Insured, Individual, ASO). Job Specific Duties: Working knowledge of medical terminology, HCPCS, CPT & ICD-10 coding applications, basic anatomy and physiology, confidentiality guidelines, pharmaceuticals, pharmacy service models in various practice settings, and pharmacy billing & pricing of pharmaceuticals. Excellent verbal and written communication skills. Excellent interpersonal and telephone skills to establish effective working relations with pharmacy providers, internal staff, members, physicians and provider office staff. Ability to catalog pharmaceutical information as it relates to condition, procedures, and billings. Ability to work independently and prioritize and organize incoming information, work, and multiple projects. Solid analytical, problem solving, research and data base maintenance skills. Ability to handle heavy workloads and competing demands in a changing environment. High degree of accuracy and attention to detail.. Working knowledge of state (where applicable) and federal pharmacy law, health insurance law, and HIPAA. Understands and monitors for fraud, waste and abuse while providing services within scope of position. Reports violations or aberrant observations according to department and company policies and procedures. Ability to quickly and accurately perform pharmaceutical calculations. Ability to obtain pertinent medical and drug related information necessary to process requests. Ability to be trained using established medical policy protocols and systems and to follow those protocols explicitly. Excellent professional judgment is required to determine those pharmacy service requests that require the escalation to a pharmacist or medical director. Follows established policies and procedures for all work assigned. Working knowledge of where to find policies and procedures. Notification of supervisor, manager, and pharmacy director if needs are identified for which no policies or procedures exist. Recognizes and notifies supervisor and pharmacy trainers of individual or identified team training needs or opportunities to improve systems. Ability to prioritize, organize, and complete all assigned tasks and projects while maintaining services standards, quality standards, and productivity standards. Proficiency with pharmacy and health plan information systems, claims processing system, and Microsoft Office applications. Ability to navigate quickly and efficiently to accomplish required job duties. Adept at utilization of multiple applications and software tools to deliver an excellent member experience and performance of assigned work with high level of quality and productivity to meet or exceed service obligations and regulatory or contractual obligations.

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