The primary purpose of the job is to:
Under the general supervision of the Supervisor of Pharmacy Prior Authorization Technicians, the Pharmacy Services Technician I assists in the prior authorization process.
• Responsible for reviewing and approving physician or member inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
• Responsible for accurate and timely data entry of prior authorization requests within the Prior authorization system to meet all client specific requirements and contractual agreements.
• Responsible for understanding and applying clinical criteria for processing Prior Authorization requests in a timely manner.
• Responsible for receiving prior authorization requests telephonically while utilizing multiple systems to confirm accuracy of the information being provided.
• Supports Fraud and Abuse program system oversight by reviewing medication utilization records. Communicates any suspected fraud discovered.
Recommends course of action for providers where patterns appears outside of guidelines and generally accepted pharmacy standards.
• Maintains a balance of productivity, quality and timeliness of job accountabilities.
• Participates in department self-audit procedures for on-going evaluation of service.
• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with internal and external business partners at all times.
• Compliance with HIPAA regulations and AMFC policies and procedures.
• Ability to adapt to a high pace changing environment.
• Strong interpersonal, written and oral communication skills.
• Attention to detail and ability to follow instructions.
• Attends required training on an annual basis.
• Strong knowledge in specialty and non-specialty pharmaceuticals
• Performs other related duties as assigned.
one to three years
• Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, retail pharmacy experience preferred.
• Minimum 35 words per minute typing speed. Current PTCB or NCCT Certificate Preferred
• High School Diploma / GED
• English: Read, Write, Speak
Certifications & Licenses:
• Current PTCB or NCCT Certificate Preferred
Skills and Experience:
• PHARMACY BENEFITS MANAGEMENT
• CLINICAL DATA ENTRY
• RETAIL PHARMACY
• Additional Skills:
• HOSPITAL PHARMACY
• MANAGED CARE