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 with operations, clinical, medical, reporting and other internal departments as needed.
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.
General Job Information
Initial Review Pharmacy Technician
United States of America
United States of America (Non-Exempt)
Recruiting Start Date
Date Requisition Created
A Combination of Education and Work Experience May Be Considered., Associates, Bachelors
License and Certifications - Required
CPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
License and Certifications - Preferred
Other Job Requirements
Minimum of 5 years of pharmacy experience without a Bachelors degree OR 2 years of pharmacy experience with a Bachelors degree in Science, Health, Medical or related field.
Pharmacy Technician certification required (CPhT), registration with a State Board of Pharmacy; must remain in good standing.
Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.
Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.
Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing.
Strong team orientation with respect for all members.
Excellent verbal and written communications skills.
People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position.
Analytic skills which can translate into practical and pragmatic recommendations.
In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology.
Oncology pharmacy or other clinical pharmacy experience.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.