Pharmacy Technician - Oahu or Maui

Pharmacy Technician

Aloha Care is a local, non-profit health plan serving Hawai`i's low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors, and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members.

Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaii's third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state.

Aloha Care employees have a passion for helping Hawai`i's most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high quality services. We support our employees with a supportive and positive work environment, healthy work-life balance, continuous communication, and a generous benefits package.

Aloha Care's leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

Aloha Care's comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

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 Aloha Care QUEST and Advantage Plus (ACAP) Plans, and provide administrative support for formulary management and compliance related functions of the Aloha Care Pharmacy Department.

• 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).
• Assist members, pharmacies, prescribers, and internal staff with pharmacy claims processing, pharmacy benefits and overrides, and provide prior authorization request status.
• Assist in prepping Medicare appeal cases for Pharmacist manager and Medical Director review.
• Assist in prepping 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)
• 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 Aloha Care policies and procedures.
• Learn and develop experience in the use of Aloha Care's information system, QMACS, and Aloha Care'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 Aloha Care policies and procedures.
• Responsible for maintaining Aloha Care's confidential information in accordance with Aloha Care policies, state and federal laws, rules and regulations regarding confidentiality. Employees…