Managed Care Pharmacy Technician

About the role

Under the direct supervision of a licensed pharmacist, the Managed Care Pharmacy Technician is responsible for administering CDPHP member and client-specific programs aimed at optimizing pharmacy benefits and the prescription process. This position handles live calls to members, physicians, and pharmacists to provide information regarding pharmacy benefits, formulary coverage, and CDPHP initiatives. The pharmacy tech supports prior authorization work under the guidance of a licensed pharmacist, implements and monitors the technical aspects of pharmacy benefits including processing medical exception requests using approved clinical algorithms, advises on pharmacy matters from internal and external sources, and performs additional ad hoc project work supporting the pharmacy department. The role participates in an on-call/holiday rotation with a utilization management pharmacist to support Plan members in after-hours pharmacy issues.

Responsibilities

• Review medical exception requests based on algorithms created by pharmacists
• Review clinical documentation against applicable criteria submitted by physicians and pharmacists to determine approval of prior authorization requests
• Assist with data entry and monitoring/researching member profiles for prior authorization requests and ad hoc reports
• Provide information via telephone to physicians and pharmacists regarding questions concerning initiatives involving member prescriptions
• Provide real-time authorization certification of requests for prescription medications for vacation supplies, duplication of therapy overrides, medication synchronization requests, and package size issues
• Implement formulary utilization management tools (prior authorization, quantity limits, step therapy, dose optimization, age/gender restrictions)
• Work with internal and external customers to identify, analyze, and solve difficult situations including system issues relative to the pharmacy benefit
• Research and resolve issues related to mail-order service, specialty pharmacy, or pharmacy claims processed in the Facets system
• Provide backup coverage to Pharmacy Benefits Team for the pharmacy phone queue line as needed
• Monitor and troubleshoot the Pharmacy Benefit Management (PBM) and other pharmacy interfaces for eligibility, claims, and formulary issues; conduct testing of interfaces as necessary
• Monitor production and quality improvement; work with management and staff to ensure quality effort supporting Pharmacy department standards
• In conjunction with the supervisor, establish productivity and quality standards
• Attend staff meetings and in-service programs as requested
• Perform rotating on-call responsibilities including holidays/evenings
• Work additional hours as needed to meet turnaround time responsibilities
• Comply with CDPHP’s Corporate Compliance Policy and all applicable laws, rules, regulations, and standards of conduct; report any suspected violations
• Perform other duties as assigned

Requirements

• High school diploma with a minimum of two years’ experience in a health-related field (associate’s degree preferred)
• Pharmacy Technician certification (CPhT), LPN, or Medical Assistant/Technologist background strongly preferred
• Basic understanding and interpretation of medical terminology and diagnosis codes
• Basic understanding of drug classes and therapeutic interchange as described in drug policies
• Clear understanding of prescription and medical benefits as they apply to the utilization review process
• Proficient experience with the Microsoft Office suite
• Strong verbal and written communication skills
• High degree of professionalism, strong work ethic, and ability to maintain a positive attitude when working with internal and external customers
• Conscientious, efficient, and accurate in prior authorization, exception, and medical/Rx necessity review processing
• Commitment to continually develop and refine skills necessary to respond to customers
• Strong customer service orientation and ability to interface effectively with internal and external customers
• Capable of working independently and applying problem-solving and analytical abilities
• Ability to cover rotating on-call responsibilities, as well as a late shift on Fridays
• Ability to work additional hours as needed to meet turnaround time responsibilities

Physical requirements

• Ability to work prolonged periods while seated at a workstation using a computer
• Ability to sit and/or stand at a workstation viewing a monitor and using a keyboard, mouse, and/or phone for three (3) or more hours at a time
• Ability to work in a home office environment for extended periods for business continuity
• Ability to hear, understand, and speak clearly while using a phone, with or without a headset

Pay

$21.20 – $33.03 per hour. Actual salary varies based on budget, prior experience, knowledge, skill, education, and internal equity.

Benefits

• Group health and/or dental insurance
• Retirement plan
• Wellness program
• Paid time away from work
• Paid holidays

Schedule

• Rotating on-call responsibilities including holidays and evenings
• Late shift on Fridays
• Additional hours as needed to meet turnaround time responsibilities
• Remote work possible on a case-by-case basis