Answer telephones in an efficient and timely manner to lend appropriate assistance to providers
Triage prior authorization requests under the supervision of a Clinical Pharmacist.
Assists in maintaining pharmacy prior authorization criteria used in the adjudication of pharmacy/specialty
claims.
Analyzing written inquiries which lends to entry and updating of pharmacy authorizations into the claimssystem.
Communicate coverage determination status to physicians and/or members and effectuate such decisionswithin the authorization tool.
Troubleshoot problems, inquiries, and new processing procedures for coverage determinations.
Assist with internal control systems and regulations compliance.
Perform other related duties as assigned.
EDUCATION AND/OR EXPERIENCE
High School Graduate of GED equivalent required. Two (2) years of college preferred.
Two (2) years experience in retail or hospital Pharmacy required.
Pharmacy Technician Certification (PTCB) preferred
Knowledge of prescription drug names, therapeutic classes and claims processing
Experience with Medicare Part D prescription benefits may be preferred for some positions
OTHER SKILLS AND ABILITIES
Expert knowledge of pharmacy claims processing
Understanding of formularies and utilization management edits
Familiarity with pharmaceutical manufacturers and product/cost information
Computer Literate (Microsoft Office Products).
Category Analyst
Function Information Technology
Req ID JN -092024-121515