Overview

To provide project coordination associated with quality assurance and review of TreatmentAuthorization Requests (TAR) for the Health Services (HS) Pharmacy Department. This positioninvolves coordinating pharmacy-related activities and initiatives requiring interdepartmental inputand participation. In addition, this position must be able to review TARs and member eligibilityaccording to PHC guidelines. Enters TAR information on TAR processing systems upon TARdetermination. Communicates with other PHC departments and external providers and partnersas necessary to address and/or resolve TAR and coverage related questions and issues.

Responsibilities

• Performs eligibility and benefit investigation to support TAR production.
• Assists Director, Pharmacy Services and Associate Director, Pharmacy Operations with regulatory documentation requests, including but not limited to:
  • Provider appeals processing, tracking, and reporting
  • Internal and external audit documentation requests
  • FWA investigation responses

• Maintains department Sharepoint site, including maintenance and updating of internal process and training documents
• Coordinates monthly analysis of pharmacy TAR data for timeliness reporting
• Coordinates platform enhancements to TAR processing systems
• Assists Associate Director, Pharmacy Operations in update and maintenance of departmentpolicies
• Supports the pharmacy department's reporting and administrative needs including data processing and extraction, distribution of pharmacy manual and formulary to members and providers, preparation of meeting packets for P&T, and other pharmacy department meetings.
• Interacts and responds to providers (pharmacy and prescribers) member service inquiries regarding pharmacy benefits, billing procedures, Coordination of Benefits, and general pharmacy issues.
• Reviews, confirms, and determines member eligibility, member benefits, and TARs.
• Communicates with pharmacy and medical providers to address formulary questions, provide formulary alternatives, and gather necessary information for TAR determination.
• Assists with operational questions from pharmacy technician staff.
• Participates in special projects, assignments, and other tasks as needed.
• Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; plus 2-3 years of college, technicalschool, or business school. Minimum of two (2) years of experience inproject coordination. Related experience in managed care, hospital, orretail pharmacy preferred.

Special Skills, Licenses and Certifications

Experience with Windows and related applications and familiarity withdata base applications. Knowledge of medical terminology and ability tounderstand and interpret medical decision making process. Knowledgeof California Medi-Cal program and benefits, TAR policies andregulations as defined by PHC and DHCS. Typing speed of 40 wpm andknowledge of general business office machine operations. ValidCalifornia Pharmacy Technician license. Pharmacy TechnicianCertification (PTCB).

Performance Based Competencies

Must be able to work in a fast paced environment and maintain courtesyand composure when dealing with internal and external customers.Prioritize work to ensure daily timeliness is met. Ability to functioneffectively with frequent interruptions and directions from multiple teammembers. Ability to prioritize work load and initiate action to acquireneeded information.

Work Environment And Physical Demands

More than 70% of work time is spent using a computer and telephone.When required, the ability to lift, carry, or move objects of varying size,weighing up to 25 lbs. Must be able to work in a fast-paced environmentand maintain courtesy and composure. Ability to function effectively withfrequent interruptions and multiple competing deadlines.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$53,701.43 - 65,784.14 

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.