Pharmacy Technician

About the role

The Pharmacy Technician supports Medicare operations delegated to our Pharmacy Benefit Manager (PBM), handles Medicare rejected claims, processes and reviews prior authorizations and coverage determinations, and provides administrative support for formulary management and compliance.

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).
• Aid members, pharmacies, prescribers, and internal staff with pharmacy claims processing, pharmacy benefits and overrides, and provide prior authorization request status.
• Aid in prepping Medicare appeal cases for Pharmacist manager and Medical Director review.
• Aid in prepping Medicare grievance cases for Pharmacist manager review.
• Efectuate Medicare appeal overturns in PBM's claim system.
• Review and process daily rejected claim and monitor claims processing for potential Fraud, Waste, and Abuse (FWA).
• Assist in administration of opioid 'lock-in' program.
• Assist in the review of pharmacy oversight reports.
• 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.
• Maintain AlohaCare's confidential information in accordance with AlohaCare policies, state and federal laws, rules and regulations regarding confidentiality.
• Responsible for maintaining 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.
• Working knowledge of Microsoft programs: Word, Excel, Outlook and PowerPoint.
• 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.

Mental, Physical and Environmental Demands

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• In an office working environment.
• May require prolonged sitting- up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.