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Pharmacy Services Intermediate - (27374-1 MTPK)
Monterey Park, California | Contract
Pharmacy Services Operations Intermediate
Provides efficient and accurate responses to external customers (physicians, office staff, pharmacy providers, members and brokers) and internal team members. Resolves outpatient pharmacy benefit coverage (inclusion/exclusion), prescription claim problems, communicates drug formulary guidelines including drug formulary alternatives, prior authorization criteria and group/member eligibility problems. Researches and solves administrative review and consumer affairs issues.
- Coordinates, assists in and supports implementation of procedures and guidelines for the drug prior authorization program for the outpatient Pharmacy Benefit
- Develops an interface with the physician, physicians office staff, medical management and other team members to ensure accurate and efficient resolution of prior authorization requests.
- Provides formulary alternatives, communicates prior authorization criteria, and discusses pharmacy benefit coverage inclusions/exclusions when required
- Interfaces in a courteous and professional manner with physicians, physician office staff, contracted pharmacists, patients, and other team members during the prior authorization process
- Provides drug usage history and other pertinent pharmacy benefit related computer searches for pharmacists and Medical Director to assist in case specific reviews and drug evaluations
- Assists pharmacists with drug utilization review programs, NCQA QI programs or other assigned projects
- Researches and resolves physician inquiries and grievances
- Provides essential clinical information to Member Services, Administrative Review Department and Consumer Affairs to resolve Member inquires and grievances
- Assists Medical Directors and Medical Management teams of all regions to evaluate and process Home Self-Administered Injectables
- Participates in, evaluates and maintains efficient workflow procedures in accordance with the clinical programs as well as the Pharmacy Departments goals and objectives
Education and Experience:
- AA Degree and 2 years of Pharmacy related experience and training; or equivalent combination of education and experience. State Board as Certified Pharm Tech required