Pharmacy Coverage Determination Jobs (NOW HIRING)

Apply online at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving Hawai`is low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors, and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members. Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaiis third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state.

The Culture:

AlohaCare employees have a passion for helping Hawai`is most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high quality services. We support our employees with a supportive and positive work environment, healthy work-life balance, continuous communication, and a generous benefits package.

AlohaCares leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCares comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Pharmacy Technician will support the oversight of Medicare operations delegated to our Pharmacy Benefit Manager (PBM), proactive Medicare rejected claim outreach, the processing and/or review of Prior Authorization/Coverage Determination, appeal and grievance requests, participate in the Medicare annual plan build implementation and testing, manage the Pharmacy help desk line, assist Customer Service on drug-related concerns/issues for the AlohaCare QUEST and Advantage Plus (ACAP) Plans, and provide administrative support for formulary management and compliance related functions of the AlohaCare Pharmacy Department.

Primary Duties and Responsibilities:

• Oversight of PBM operations in regard to Medicare Part D and Part B delegated operations through auditing operational reports and utilizing the PBMs processing platforms.
• Issue resolution of Part D and Part B claim issues through working with the PBM operations team.
• Test case build and claim testing review for annual Medicare plan go-live and off-cycle launches.
• Daily Medicare rejected claim review to proactively resolve member rejected claims. Proactive outreach to pharmacy to explain why a claim hit an edit, formulary options, or contact doctors office to expedite coverage determinations in order to enhance members care and prevent member dissatisfaction with the plan.
• Process and review all prior authorization (PA)/coverage determination (CD) requests in an accurate and timely manner.
• Adhere to turnaround times (TAT) for PAs/CDs as required by the Centers for Medicare & Medicaid Services (CMS), Med-QUEST (Hawaii Medicaid), and National Committee for Quality Assurance (NCQA).
• Assist members, pharmacies, prescribers, and internal staff with pharmacy claims processing, pharmacy benefits and overrides, and provide prior authorization request status.
• Assist in prepping Medicare appeal cases for Pharmacist manager and Medical Director review.
• Assist in prepping Medicare grievance cases for Pharmacist manager review.
• Effectuate Medicare appeal overturns in PBMs claim system.
• Review and process daily rejected claim and monitoring of claims processing for potential Fraud, Waste, and Abuse (FWA)
• Assist in administration of opioid lock-in program
• Assist in the review of pharmacy oversight reports
• Outreach to members to assist with medication adherence and other HEDIS/Medicare Part D related measures
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Learn and develop experience in the use of AlohaCares information system, QMACS, and AlohaCares historical databases
• Learn and develop experience in the use of PBM websites and various reporting tools as well as the claims and authorization processing platform/system sponsored by the PBM.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCares confidential information in accordance with AlohaCare policies, state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• High school diploma or equivalent.

• Minimum of 2 years of experience in pharmacy or equivalent combination of education and experience.

• Ability to type 45 words per minute (WPM).

• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
• Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
• Professional telephonic etiquette skills.
• Ability to solve problems, analyze, think critically, and make good judgments.
• Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.

• Possesses excellent time management and organizational skills; dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Data entry experience with a high degree of accuracy and attention to detail.

• Working knowledge of Microsoft programs: Word, Excel, Outlook and PowerPoint.
• Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.

Preferred Requirements:

• Nationally Certified Pharmacy Technician (CPhT).

• College Degree in science-related field or equivalent combination of education and experience.

• Pharmacy Technician experience at a managed care organization (MCO) or Pharmacy Benefits Manager (PBM).
• Health care data system experience.
• Understand the principles of managed care pharmacy.
• Pharmacy claims processing computer system experience.
• Thorough knowledge of the principals and protocols of the medication prior authorization process and managed care pharmacy experience and/or retail pharmacy experience of not less than two years
• Intermediate skills in Microsoft Programs: Word, Excel, Outlook, and PowerPoint.

Mental, Physical and Environmental Demands:

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• In an office working environment.
• May require prolonged sitting- up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.

Salary Range $20.00 - $26.00 an hour

AlohaCare is committed to providing equal employment opportunities to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.