Utilization Review Jobs in Rochester, NY (NOW HIRING)

Job Description:

Under the direct supervision of a licensed pharmacist, the Managed Care Pharmacy Technician (Pharmacy Tech) is responsible for administering CDPHP member and client-specific programs aimed at optimizing pharmacy benefits and the prescription process. This position will handle live calls to members as well as physicians and pharmacists, to provide information regarding pharmacy benefits, formulary coverage and CDPHP initiatives. The pharmacy tech will support initiatives including prior authorization work under the guidance of a licensed pharmacist. The pharmacy tech is responsible for implementing and monitoring the technical aspects of pharmacy benefits including the processing of medical exception requests using approved clinical algorithms, advising on pharmacy matters from internal and external sources, as well as additional ad hoc project work which supports the pharmacy department. The pharmacy tech will participate in an on-call/holiday rotation along with a utilization management pharmacist to support Plan members in after hour pharmacy issues.

Essential Accountabilities:

• Review of medical exception requests based on algorithms created by pharmacists.
• Review clinical documentation against applicable criteria submitted by physicians and pharmacists to determine approval of request for prior authorization.
• Assist with data entry and monitoring/researching member profiles for prior authorization requests and ad hoc reports.
• Provide information via telephone to physicians and pharmacists regarding questions concerning initiatives involving member prescriptions.
• Provide real time authorization certification of requests for prescription medications for vacation supplies, duplication of therapy overrides, medication synchronization requests and package size issues.
• Implement formulary utilization management tools (i.e. prior authorization, quantity limits, step therapy, dose optimization, age/gender restrictions)
• Work with internal and external customers to identify, analyze and solve difficult situations including system issues relative to the Pharmacy benefit.
• Research and resolve issues related to mail-order service, specialty pharmacy, or pharmacy claims processed in the Facets system at the Plan.
• Provide backup coverage to Pharmacy Benefits Team for the pharmacy phone queue line as needed, to assist in providing service to internal departments, external practitioners and pharmacists calling with questions and/or problems pertaining to the pharmacy benefit.
• Monitor and troubleshoot the Pharmacy Benefit Management (PBM) and other pharmacy interfaces for eligibility, claims, and formulary issues. Conduct testing of the interfaces as necessary.
• Monitor production and quality improvement. Work with management and staff to ensure quality effort that supports the Pharmacy department standards. In conjunction with the supervisor, establish productivity and quality standards.
• Attend staff meetings and in-service programs as requested.
• Perform rotating on-call responsibilities including holidays/evenings.
• Work additional hours as needed in order to meet turnaround time responsibilities.
• The employee agrees to comply with CDPHP's Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the Corporate Compliance Policy and has a duty and obligation to report any suspected violations of any law, the standards of conduct or Corporate Compliance Policy to his or her immediate Supervisor, the fraud and abuse hotline, the Compliance Officer, the Compliance Director, Human Capital Management or the Chief Executive Officer.
• Perform other duties as assigned.

Minimum Qualifications:

• High school diploma with a minimum of two years' experience in health-related field is required. Associates degree preferred.
• Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
• Basic understanding and interpretation of medical terminology and diagnosis codes required.
• Basic understanding of drug classes and therapeutic interchange as described in the drug policies.
• A clear understanding of prescription and medical benefits as it applies to the utilization review process.
• Must demonstrate proficient experience with the Microsoft Office suite.
• Strong verbal and written communication skills are required.
• Must possess a high degree of professionalism, strong work ethic and the ability to maintain a positive attitude when working with internal and external customers.
• Must be conscientious, efficient and accurate in prior authorization, exception and medical/Rx necessity review processing.
• Continually strive to develop and/or refine skills necessary to respond to customers.
• Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
• Capable of working independently and applying problem solving and analytical abilities.
• Ability to cover rotating on-call responsibilities, as well as a late shift on Fridays.
• Ability to work additional hours as needed in order to meet turnaround time responsibilities.

Physical Requirements:

• Ability to work prolonged periods while seated at a workstation using a computer.
• Ability to sit and/or stand at a workstation viewing a monitor and using a keyboard, mouse, and/or phone for three (3) or more hours at a time.
• Ability to work in a home office environment for extended periods for business continuity.
• Ability to hear, understand, and speak clearly while using a phone, with or without a headset.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

$21.20 - $33.03

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.