Remote Pharmacy Technician

Job Title:

Remote Pharmacy Technician

Job Description

This role involves performing technically detailed pharmacy and benefit work that impacts pharmacy and health plan operations, programs, and information systems within the Pharmacy Services Department. The position integrates technical pharmacy aspects with medical review, case management, mental health/chemical dependency, and quality management. As a Remote Pharmacy Technician, you will communicate directly with customer service teams, network pharmacies, regulatory entities, pharmacists, nurses, physicians, and other healthcare providers to manage claims, medication management programs, and initiatives.

Responsibilities

+ Provide excellent member care by resolving issues and creating a smooth experience during first-contact interactions.

+ Maintain strong customer service with external partners, including pharmacies, prescribers, and caregivers, to build lasting relationships.

+ Serve as a liaison and problem-solver across providers, members, payors, and internal departments.

+ Identify and respond to medical preauthorization requests requiring urgent clinical review.

+ Manage multiple priorities and deadlines independently while collaborating effectively with the team.

+ Administer pharmacy benefits, pharmacy network contracts, and employer group contracts in alignment with organizational goals and regulatory requirements.

+ Apply knowledge of medical drug benefits and channel management, including contracted networks and policies.

+ Interpret and respond to member behavior and self-reported information across all age populations to support individualized care needs.

+ Independently coordinate and process pharmacy prior authorizations using benefit plans, utilization policies, approval criteria, prescriber information, and patient-specific factors.

+ Maintain member eligibility processes and databases; oversee daily claims transactions and escalate irregularities.

+ Answer, triage, and document incoming calls and requests, resolving or routing them appropriately based on urgency and protocols.

+ Perform intake and data entry for authorizations, referrals, demographics, discharge data, medication therapy management, and utilization management.

+ Use judgment to escalate cases requiring pharmacist or physician intervention according to established guidelines.

+ Assign accurate coding for services, diagnoses, procedures, and identifiers using ICD-10 and CPT-4 systems.

+ Provide coding support and technical assistance to clinical reviewers.

+ Conduct system searches to gather documentation for case review and assist with loss report maintenance.

+ Communicate prior authorization outcomes and medication-related issues to prescribers, including documentation of communication.

+ Act as a departmental resource for members, providers, and internal teams to address workflow, system, and process questions.

+ Communicate with members, pharmacies, and providers to obtain necessary information, approvals, and signatures; draft written communications as needed.

+ Audit claims, documentation, and correspondence for accuracy, completeness, and quality.

+ Support customer service, marketing, provider relations, and other stakeholders with information and communication needs.

+ Train providers, office staff, members, payors, and internal teams on pharmacy processes and system usage.

+ Serve as a subject matter resource on pharmacy operations and health plan processes within scope.

+ Maintain confidentiality and security of medical records, ensuring compliance with record retention and purge protocols.

+ Track, analyze, and report work activity data; develop reports to measure quality and effectiveness and recommend improvements.

+ Research and resolve pending claims, authorizations, and incomplete records.

+ Authorize payment of pharmacy claims and direct member reimbursements per policy.

+ Collect, organize, review, and verify records from prescribers and pharmacies for regulatory compliance and audits.

+ Maintain working knowledge of health plan pharmacy operations, policies, procedures, and healthcare regulations.

+ Identify and communicate training needs or system improvement…