Pharmacy Technician

About the role

The Pharmacy Technician will support the oversight of Medicare operations delegated to our Pharmacy Benefit Manager (PBM), proactive Medicare rejected claim outreach, the processing and/or review of Prior Authorization/Coverage Determination, appeal and grievance requests, participate in the Medicare annual plan build implementation and testing, manage the Pharmacy help desk line, assist Customer Service on drug-related concerns/issues for the AlohaCare QUEST and Advantage Plus (ACAP) Plans, and provide administrative support for formulary management and compliance related functions of the AlohaCare Pharmacy Department.

Responsibilities

• Oversight of PBM operations in regard to Medicare Part D and Part B delegated operations through auditing operational reports and utilizing the PBM’s processing platforms.
• Issue resolution of Part D and Part B claim issues through working with the PBM operations team.
• Test case build and claim testing review for annual Medicare plan go-live and off-cycle launches.
• Daily Medicare rejected claim review to proactively resolve member rejected claims.
• Proactive outreach to pharmacy to explain why a claim hit an edit, formulary options, or contact doctor’s office to expedite coverage determinations in order to enhance member’s care and prevent member dissatisfaction with the plan.
• Process and review all prior authorization (PA)/coverage determination (CD) requests in an accurate and timely manner.
• Adhere to turnaround times (TAT) for PAs/CDs as required by the Centers for Medicare & Medicaid Services (CMS), Med-QUEST (Hawaii Medicaid), and National Committee for Quality Assurance (NCQA).
• Absorb and provide prior authorization request status to members, pharmacies, prescribers, and internal staff.
• Absorb and prepare Medicare appeal cases for Pharmacist manager and Medical Director review.
• Absorb and prepare Medicare grievance cases for Pharmacist manager review.
• Effectuate Medicare appeal overturns in PBM’s claim system.
• Review and process daily rejected claim and monitoring of claims processing for potential Fraud, Waste, and Abuse (FWA).
• Absorb and assist in the ‘‘lock-in” program for opioids.
• Absorb and assist in the review of pharmacy oversight reports.
• Absorb and assist in outreach to members to assist with medication adherence and other HEDIS/Medicare Part D related measures.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Learn and develop experience in the use of AlohaCare’s information system, QMACS, and AlohaCare’s historical databases.
• Learn and develop experience in the use of PBM websites and various reporting tools as well as the claims and authorization processing platform/system sponsored by the PBM.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Maintain AlohaCare’s confidential information in accordance with AlohaCare policies, state and federal laws, rules and regulations regarding confidentiality.

Requirements

• High school diploma or equivalent.
• Minimum of 2 years of experience in pharmacy or equivalent combination of education and experience.
• Ability to type 45 words per minute (WPM).
• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
• Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
• Professional telephonic etiquette skills.
• Ability to solve problems, analyze, think critically, and make good judgments.
• Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
• Possesses excellent time management and organizational skills; dependable, enthusiastic, self-starting, and self-motivated.
• Uses time effectively, reacts professionally under pressure.
• Data entry experience with a high degree of accuracy and attention to detail.
• Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.

Preferred Requirements

• Nationally Certified Pharmacy Technician (CPhT).
• College Degree in science-related field or equivalent combination of education and experience.
• Pharmacy Technician experience at a managed care organization (MCO) or Pharmacy Benefits Manager (PBM).
• Health care data system experience.
• Understand the principles of managed care pharmacy.
• Pharmacy claims processing computer system experience.
• Thorough knowledge of the principals and protocols of the medication prior authorization process and managed care pharmacy experience and/or retail pharmacy experience of not less than two years.
• Intermediate skills in Microsoft Programs: Word, Excel, Outlook, and PowerPoint.