Position Summary :

This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and / or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects.

Must maintain performance in compliance with organizational or department goals and in compliance with regulatory agencies

Primary Responsibilities / Accountabilities :

• Process prior authorizations received via prior authorization help line, by evaluating the medical necessity / appropriateness for specific drugs and based on medical criteria.
• Directly interact with members physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues.
• Conduct intervention with physician & pharmacy office staff to facilitate formulary compliance and generic dispensing.
• Process appeals complaints executive inquiries and compliance related issues.
• Provide recommendations to increase efficiency, accuracy and productivity in the department.
• Process ad hoc request for information or reports from stakeholders.
• Participate in client member and employee training to ensure practical understanding of pharmacy services programs and operations.
• Assist in the day to day business functions of the pharmacy department as well as the Medication Therapy Management program.
• Provide support to various clinical programs within the pharmacy department.

Qualifications :

• Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration.
• Requires minimum of two () years experience in third party prescription program claim adjudication.
• Requires minimum of two () years experience as a Pharmacy Utilization Management Specialist.

Last updated : 2024-05-24