Gateway Health Plan
Job Description :
This opportunity provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.
Essential Job Functions:
- Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner.
- Interact with staff to implement processes and problem solves.
- Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department.
- Prioritize requests for drug authorizations or denials.
- Review of prior authorization criteria for drug products.
- Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity.
- Ensure adherence to call center turn around time requirements associated with DPW/CMS regulations.
- Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override.
- Search member claim history profile and recommend formulary alternatives wherever feasible.
- Contact physician network provider to obtain necessary and/or additional information when necessary.
- Consult with staff clinical pharmacist for guidance and assistance as necessary.
- Document all authorizations and denials completely, accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member.
- Populate all authorization and denial information fields within the OnBase information system.
- Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
- Complete other assigned duties as specified.
- Identify and report improper coordination of benefit billing practices through paid clams review.
- Participate as pharmacy representative in onsite member appeals and grievances sessions.
- Serve as a resource for technical staff.
- Other duties as assigned or requested.
- High school diploma or GED
- Experience in pharmacy prescription claims processing/submission/payment.
- Associate degree
- Pharmacy technician certification certificate
- Experience working in a managed care medication formulary management environment
- Working knowledge of retail pharmacy and/or third party prescription procession
- Strong background and understanding of medications and formulary terminology
- Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation
Referral Bonus: Level 1
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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