Under the direction of the Pharmacy Program Specialist Supervisor, the Pharmacy Program Specialist is responsible for the technical review of the prescription drug prior authorization and utilization management authorization with a medication component; and notifying the provider of the clinical decision.
1. Technical review of authorizations (drug and utilization management) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation.
2. Decision prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
3. Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
4. Ensure all company's goals (including, but not limited to the 5 Strategic Priorities: Quality of Care and Service, Access to Care, Practice Transformation, Human Development and Technology and Data Analytics).
5. Communicate with providers (doctor and pharmacy) on issues related to the IEHP formulary, non-formulary criteria, or respective policies and procedures.
6. Interface with IEHP's pharmacy benefit management (PBM) company, when necessary, in regards to adjudication and medication processing issues.
7. Assist in expedited review of discharge related orders or requests and coordination with specialty pharmacy providers (disease therapy management program), and internally with Utilization Management, Behavioral Health, or Care Management departments.
8. Assist Clinical Pharmacist in review of Member's medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments.
9. Actively participate in internal quality improvement process enhancements, LEAN projects, and managing for daily improvement (MDI).
10. Participate in various pharmacy projects to meet the standards of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Projects included, but not limited to, pharmacy utilization management review, provider and pharmacy outreach, formulary alternative conversion and discharge medication transition.
11. Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues.
Three (3) or more years of experience as a pharmacy technician in a pharmacy required.
Experience in a pharmacy benefit management setting preferred.
High school diploma or GED required.
Associates degree, Bachelor of Arts or Bachelor of Science degree from an accredited institution preferred.
Possession of an Active, unrestricted, and unencumbered Pharmacy Technician license issued by the California State Board of Pharmacy
Knowledge in pharmaceutical terminology is required.
Highly motivated and good interpersonal skills, self-starter. Display the ability to adapt and perform duties efficiently whenever unexpected changes arise. Works well in a fast-paced environment. Detail-oriented.
Data Entry and review of Pharmacy prior authorization requests, along with Provider outreach calls.
(3) temporary openings Assignment length: Until mid March 2020
Please note that the assignment is for Medi-Cal and a Pharmacy test will be conducted onsite before the interview.