Remote Pharmacy Technician

Job Title:

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, prior authorization, and oversight and audit support. Using established guidelines, this role reviews and processes requests from physicians, medical groups, pharmacies, and members for prescription drug use and pharmacy benefits, researches and resolves issues, and collaborates with clinical pharmacists and other clinical leaders to ensure accurate, compliant, and timely pharmacy benefit administration.

Responsibilities

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

+ Submit and maintain formulary change requests with the pharmacy claims processor and ensure accurate setup.

+ Generate, maintain, and review formulary status grids to support accurate benefit administration.

+ Use reports to perform audits and quality checks on current 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 document findings clearly and accurately.

+ Correspond with pharmacies regarding audit findings and fax inquiries related to review outcomes.

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

+ Update an Access database with details of incoming phone calls, faxes, and emails to ensure accurate records.

+ Take member inquiry calls related to pharmacy benefit questions, including prior authorization requests.

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

+ Educate members on their specific pharmacy benefits and explain available options, including prior authorization requests.

+ Process member-submitted pharmacy claims accurately and within established time frames.

+ Review requests from physicians and pharmacies for non-formulary drugs, drugs requiring prior authorization, and drugs exceeding quantity or cost limits.

+ 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 guidelines.

+ Maintain thorough knowledge of pharmacy and medical benefits to support accurate decision-making.

+ Review and process Prescription Drug Event (PDE) files for Medicare Part D operations.

+ Research and resolve issues related to PDE files and claims using appropriate reference materials.

+ Assist with pharmacy claims correction projects and perform audits and quality checks on active prior authorization claims.

+ Assist with identifying and correcting eligibility and group issues that impact pharmacy claims and benefits.

+ Process member claims related to Medicare Part D operations.

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

+ Resolve operational issues related to prior authorization, appeals and grievances, and member or provider services.

+ Prepare and review operational reports and audits for state health programs.

+ 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 direct member reimbursement (DMR) requests.

+ Assist with state health program clinical projects and Medi-Cal prior authorizations.

+ Assist in the implementation of regulatory changes affecting pharmacy operations.

+ Participate in maintaining consistent processes and methods for developing, implementing, communicating, and training on new or updated policies and procedures.

+ Collaborate with business units and departments to ensure end-to-end process connectivity and effective handoffs across multiple departments.

+ Provide support and monitoring to help ensure compliance of first tier, downstream, and related entities.

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

+ Identify the validity of appeals and determine the appropriate handling of each request.

+ Redirect non-valid appeals to the correct department with clear documentation.

+ Verify drug, dosage, quantity, provider, and diagnosis information for appeals.

+ Research formularies and prior authorization criteria to determine if additional information is needed for appeals.

+ Contact providers and members to obtain additional information and clearly…