From Home Express Scripts Pharmacy Jobs in Riverside, CA

Job location: Orange CA

Duration: Full Time + Benefits

This position will provide triage and administrative support as it relates to the preparation, and review management of individual workers compensation, and other claims being serviced by clients Physician Guides (PG).

The candidate will proactively triage and make effective decisions to coordinate work performed by physician resources in order to maximize their efficiency in performing the function of the Physician Guide, while supporting other needs of the Clinical Services product line.

Department: Clinical Services

Reports To: AVP of Clinical Services

Essential Duties And Responsibilities Include The Following. Other Duties May Be Assigned.

Conducting Case Referral Setup For New Physician Guide Assignments To Include:

Maintaining spreadsheet of ongoing cases with QA reminders on shared drive

Gathering all medical documentation available in appropriate software systems, or hard files for scanning, and uploading the documents to the medical care software. Phone calls to provider offices may be required.

Obtaining, and confirming all pertinent injured worker demographics and vendors for appropriate assignment

Scheduling For Physician Guides

Setup of all necessary aspects of claim and assignment to designated Physician Guide

Setting up task assignments in clinical software for any Curbside Consult needed on Non Physician Guide cases

Planning Roundtable, and follow-up Roundtables, with Claims Examiner, with initial Roundtable 2 weeks post initial assignment, and following Roundtables at the discretion of Claims Examiner and/or Physician Guide.

Follow-up Support For Physician Guides

During the term of their assignment to gather information, and assist in referrals to specialists if this becomes part of the treatment plan agreed upon between Provider and Physician Guide.

Regarding post-surgical patients, participate with coordination of discharging planning needs as directed by assigned Physician Guide.

Documenting updates into managed care software system as needed for all activities, per request of Physician Guides.

Preparing and sending to all stakeholders, including provider, injured worker, attorneys, and servicing vendors, and in accordance with state required timelines, any utilization review determination letters which are certified by the Physician Guides

Uploading and documenting all acknowledgements and responses received from any stakeholder into medical management software for Physician Guide cases, and delivering notification of receipt of such to claims examiners and Physician Guides.

At the Physician Guide's direction, preparing and forwarding to clients Utilization Review department, any treatment or service requests which are not certified by the PG and which require full formal Utilization Review. Receive and upload into clinical software written documentation of clients

Utilization Review decisions of all treatments and services reviewed.

Coordinating workflow for all medication requests for PG and Non PG cases

Upon reassignment from claims examiner to managed care coordinator, load medication fill history and medication requests received from Express Scripts on cases assigned to Physician Guide and for PG to review. Assists PGs in submission of Approval of medications in Oasis, the Express Scripts portal.

With medication requests not approved by Physician Guides on PG cases, MCC will prepare and submit to clients UR department for full formal Utilization Review.

With medication requests not approved by Pharmacy Guides on Non PG cases, MCC will assist in delivery of medication requests to Clients UR for review

Receives and uploads into clinical software written documentation of clients Utilization Review decisions on all medication referrals.

Entering documentation in managed care software for PG closures upon direction.

Ability To Identify And Resolve Problems In A Timely Manner; Gather And Analyse Information Skillfully.

Ability To Demonstrate Accuracy And Thoroughness, Monitor Own Work To Ensure Quality And Apply Feedback To Improve Performance.

Ability To Adapt To Changes In The Work Environment, Manage Competing Demands And Is Able To Deal With Frequent Change, Delays Or Unexpected Events.

Ability To Be At Work And On Time, Follow Instructions, Respond To Management Direction And Solicit Feedback To Improve Performance

Ability To Work Independently And Work As An Active Team Player

Ability To Communicate With All Clients, Vendors, Providers, Etc., With A High Level Of Professionalism.

Detail Oriented

Strong Organizational Skills

Ability To Multi-task

Computer Skills (Microsoft Applications)

Excellent Written And Verbal Communication Skills

High School Or GED Required; Bachelors Preferred. Experience In A Medical Care Environment; Workers' Compensation And Or Insurance Environment Preferred.

Technology Experience To Include Ease With Word, Outlook, Excel, Access, And Power Point Preferred.

While Performing The Duties Of This Job, The Employee Is Occasionally Required To Stand; Walk; Sit; Use Hands To Finger, Handle, Or Feel Objects, Tools Or Controls; Reach With Hands And Arms; Climb Stairs; Balance; Stoop, Kneel, Crouch Or Crawl; Talk Or Hear; Taste Or Smell. The Employee Must Occasionally Lift And/Or Move Up To 25 Pounds.

Office Environment.