Support providers (pharmacists and physicians) with Commercial pharmacy/ specialty drug benefits analysis, drug coverage inquiries and prior authorization
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Answer telephones in an efficient and timely manner to lend appropriate assistance to providers
- Triage prior authorization requests under the supervision of a Clinical Pharmacist.
- Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/specialty claims.
- Analyzing written inquiries which lends to entry and updating of pharmacy authorizations into the claims system.
- Communicate coverage determination status to physicians and/or members and effectuate such decisions within the authorization tool.
- Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
- Assist with internal control systems and regulations compliance.
- Perform other related duties as assigned.
Top 3 Required Skills/Experience –
• 2 years retail pharmacy experience
• Knowledge of adjudicating pharmacy claims
• Computer Literate (Microsoft Office Products)
Required Skills/Experience – The rest of the required skills/experience. Include:
• Two (2) years experience in retail Pharmacy required.
• Knowledge of prescription drug names, therapeutic classes and claims processing
• Expert knowledge of pharmacy claims processing
Preferred Skills/Experience – Optional but preferred skills/experience. Include:
Education/Certifications – Include:
• High School Graduate of GED equivalent required. Two (2) years of college preferred
• Pharmacy Technician Certification (PTCB) preferred
Function Information Technology
Req ID JN -022023-119723