Adjudication, Clinical Support, Customer Service Evaluation, Documentation Review, Formulary, Maintain Compliance, Medical Office, Pharmacy, Quality Assurance, Regulatory Compliance, Request for Information (RFI), Staff Training
Location: Remote
Duration: 6+ Months (Possible extension)
Job Summary:
This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including generating correspondence and special projects. Must maintain performance in compliance with organizational or department goals and in compliance with regulatory agencies
Responsibilities:
Process prior authorizations received via prior authorization help line and fax application by reviewing the documents, evaluating for accuracy and completeness of the medical necessity forms for specific drugs based on provided criteria. Submit for clinical review and determination.
- Directly interact with members physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues.
- Conduct intervention with physician & pharmacy office staff to facilitate formulary compliance and generic dispensing.
- Provide recommendations to increase efficiency, accuracy and productivity in the department.
- Process ad hoc request for information or reports from stakeholders.
- Participate in client member and employee training to ensure practical understanding of pharmacy services programs and operations.
- Assist in the day to day business functions of the pharmacy department.
- Provide support to various clinical programs within the pharmacy department.
Education/Experience:
-National Pharmacy Certification preferred.
- Requires minimum of two (2) years experience in third party prescription program claim adjudication.
- Requires minimum of two (2) years experience as a Pharmacy Technician.
- Requires prior customer service/service quality initiative experience.A
Alpha Business Solutions