Remote Pharmacy Technician

Remote Pharmacy Technician Opportunity

This Pharmacy Technician role supports multiple pharmacy operations areas, including formulary management, prior authorization, pharmacy audit and recovery, Medicare Part D and Part B, appeals, Medicare Part D operations, state health programs pharmacy operations, and pharmacy service center functions. You will review and process requests from physicians, medical groups, pharmacies, and members for prescription drugs and pharmacy benefits, research and resolve issues, and collaborate closely with clinical pharmacists and other clinical and operational teams to ensure accurate, compliant, and timely service.

Responsibilities

• Review and process formulary change requests from health plans and submit and maintain these requests in the pharmacy claims processing system.
• Generate, maintain, and review formulary status grids and 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 pharmacy audit and recovery assignments, including reviewing paid claims for quantity and billing discrepancies and communicating findings to pharmacies.
• Fax inquiries to pharmacies related to audit findings, respond to incoming calls and faxed correspondence from pharmacies, and update the Access database with phone, fax, and email interactions.
• Handle member inquiry calls regarding pharmacy benefits, including prior authorization requests, and maintain expert knowledge of Medicare pharmacy benefits, formularies, and applicable regulations.
• Educate members about their specific pharmacy benefits and available options, including submitting prior authorization requests, and process member-submitted claims.
• Review requests from physicians and pharmacies for non-formulary drugs, drugs requiring prior authorization, drugs exceeding quantity or cost limits, or those needing assistance with online claim processing.
• Assign, enter, and document prior authorizations in the appropriate claims processing systems and answer phone calls related to prior authorization inquiries.
• Research and resolve prior authorization issues using appropriate reference materials and maintain a thorough understanding of pharmacy and medical benefits.
• Review and process PDE files for Medicare Part D operations, research and resolve related issues, and assist with pharmacy claims correction projects.
• Perform audits and quality checks on active prior authorization claims and assist with identifying and correcting eligibility and group issues, including processing member claims.
• Serve as a liaison to internal and external departments for state health program pharmacy operations and support operational issue resolution from prior authorization, appeals and grievances, and member or provider services.
• Prepare and review various operational reports and audits, perform formulary management functions for state health programs, and support quarterly formulary updates to websites, databases, and benefit maintenance.
• Maintain prior authorization database files, process Medi-Cal DMRs, assist with state health program clinical projects, and support Medi-Cal prior authorizations.
• Assist with the implementation of regulatory changes and participate in maintaining consistent processes 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 appropriate handoffs across policies and procedures spanning multiple departments.
• Provide support and monitoring to help ensure compliance of first tier, downstream, and related entities and assist with department preparation for internal and external audits, including building case files, universes, and evidence of compliance.
• Identify the validity of appeals and route non-valid appeals to the appropriate department while verifying drug, dosage, quantity, provider, and diagnosis information.
• Research appeals using formularies and prior authorization criteria to determine if additional information is needed and reach out to providers and members to clearly communicate required information.
• Complete other appeal-related tasks as assigned.
• Track and triage coverage determination and prior authorization requests for Medicare Part D and Part B, determine when pharmacist review is required, and obtain verbal authorizations and detailed clinical information from prescribers.
• Approve coverage determination and prior authorization requests based on defined criteria and enter and document decisions in the PBM system while notifying providers and members.
• Respond to client inquiries regarding authorization approvals and PBM online processes, refer coverage determination requests for specialty drugs to delegated vendors or clients, and contact providers for additional information to facilitate reviews.
• Notify physicians, providers, and…