What are the responsibilities and job description for the Initial Review Pharmacy Technician position at Prime Therapeutics LLC?
Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.
Job Posting Title
Initial Review Pharmacy Technician Job Description
Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan / payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Recommendations will be based on an in-depth understanding of specific specialty medications and industry guidelines, on both pre- and post-service requests. Coordinates withoperations, clinical, medical, reporting and other internal departments as needed.
Responsibilities
- Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria. Refers all cases not meeting clinical criteria to pharmacist clinical reviewer.
- Practices and maintains the principles of utilization management by adhering to the company policies and procedures. Upholds clinical integrity of pharmaceutical solutions by participating in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. Expert within the organization.
- Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client.
- Assists with the documentation and implementation of both written and verbal communications to physicians / prescribers and assists in the maintenance of the edits and data elements that support the edits.
- Available for consultation in pharmacy related questions to resolve claims submission related to medication edits.
- Contacts physicians / prescribers to obtain pertinent clinical history / information. Provides optimum customer service through professional / accurate communication while maintaining NCQA and health plan`s required timeframes.
- Regularly reviews and monitors information on pended claims identified as outliers by internal and / or external analysis of pharmacy claims data.
- Supports Intake call volume and order entry if necessary.
- Determines eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enters approvals or denials in the system.
- Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies.
- Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary.
- Other duties as assigned.
Education & Experience
Must be eligible to work in the United States without the need for work visa or residency sponsorship.
Additional Qualifications
Preferred Qualifications
Physical Demands
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Potential pay for this position ranges from $23.08 - $37.02 based on experience and skills.
To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.
Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, creed, color, religion, gender, sexual orientation, gender identity / expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, or any other basis protected by law.
We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.
Prime Therapeutics LLC is a Tobacco-Free Workplace employer.
Positions will be posted for a minimum of five consecutive workdays.
Salary : $23 - $37
