100% REMOTE Pharmacy Technician

100% REMOTE Pharmacy Technician

Job Description

The Pharmacy Technician supports multiple pharmacy operations areas, including formulary management, pharmacy audit and recovery, pharmacy service center, Medicare Part D and Part B, appeals, state health programs pharmacy operations, and prior authorization. Working within established guidelines, this role reviews requests from physicians, medical groups, pharmacies, and members for prescription drug use and pharmacy benefits, researches and resolves questions and issues, and collaborates with clinical pharmacists and other clinical staff to ensure accurate, compliant, and timely processing of claims and authorizations.

Responsibilities

+ Review and process formulary change requests from health plans in accordance with established procedures.

+ Submit and maintain formulary change requests with the pharmacy claims processor to ensure accurate benefit configuration.

+ Generate, maintain, and review formulary status grids to track current formulary positions.

+ Use reports to perform audits and quality checks on formulary status for accuracy and contract compliance.

+ Assist clinical pharmacists with formulary database maintenance and updates to the company website.

+ Perform a variety of assignments related to pharmacy audit and recovery functions.

+ Review paid claims for quantity and billing discrepancies and communicate findings to pharmacies.

+ Fax inquiries to pharmacies related to review findings and follow up as needed.

+ Answer incoming calls and respond to faxed correspondence from pharmacies regarding audit and recovery issues.

+ Update Access databases with information from incoming phone calls, faxes, and emails.

+ Take member inquiry calls regarding pharmacy benefits, including questions about prior authorization requirements.

+ Maintain expert knowledge of Medicare pharmacy benefits and formularies, including relevant CMS regulations.

+ Educate members on their specific pharmacy benefits and present options, including submission of prior authorization requests.

+ Process member-submitted pharmacy claims accurately and in a timely manner.

+ Review requests from physicians and pharmacies for prescription drugs that are non-formulary, require prior authorization, exceed quantity or cost limits, or need assistance with online claim processing.

+ Assign, enter, and document prior authorizations into the appropriate claims processing system.

+ Answer phone calls related to prior authorization inquiries and provide clear, accurate information.

+ Research and resolve prior authorization issues using appropriate reference materials and resources.

+ Maintain thorough knowledge of pharmacy and medical benefits to interpret and apply benefit rules correctly.

+ Review and process Medicare Part D PDE files in accordance with regulatory and internal standards.

+ Research and resolve Medicare Part D operational issues using appropriate reference materials.

+ Assist with pharmacy claims correction projects to ensure accurate payment and benefit application.

+ Perform audits and quality checks on active prior authorization claims to verify compliance and accuracy.

+ Assist with identifying and correcting eligibility and group configuration issues impacting pharmacy claims.

+ Process member claims for Medicare Part D and related programs as needed.

+ Act as a liaison to internal and external departments for state health programs pharmacy operations.

+ Resolve operational issues originating from prior authorization, appeals and grievances, and member or provider services.

+ Prepare and review various operational reports and audits related to state health programs pharmacy operations.

+ Perform formulary management functions for state health programs, including quarterly formulary updates to the website, database, and benefit maintenance.

+ Maintain prior authorization database files for state health programs.

+ Process Medi-Cal DMR requests and related documentation.

+ Assist with state health program clinical projects and initiatives.

+ Assist with Medi-Cal prior authorizations, ensuring accurate and timely processing.

+ Assist in implementing regulatory changes affecting pharmacy operations and benefits.

+ Participate in maintaining consistent processes and methods for development, implementation, communication, and training on new or updated policies and procedures.

+ Work with business units and departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into policies and procedures spanning multiple departments.

+ Provide support and monitoring to help ensure compliance of First Tier, Downstream, and Related Entities (FDRs).

+ Assist with departmental preparation for internal and external audits, including building case files, universes, evidence of compliance, and other documentation.

+ Identify the validity of appeals and determine whether they meet criteria for formal appeal processing.

+ Redirect non-valid appeals to the appropriate department for…