Clinical Pharmacy Review Technician

Overview

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

How you belong matters here. We value our employees' differences and find strength in the diversity of our team and community.

Now hiring Clinical Pharmacy Review Technician

Summary:The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.This position is responsible for providing clinical support for the Fluent Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances.Full Time - Exempt: No Job is based Rev Hugh Cooper Admin Center Work hours: Days

Qualifications

*GED or High School diploma is required.*Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred*Retail Pharmacy experience preferred *Managed care customer service experience preferred*Drug Information skills*Experience with Medicare Part D insurance and Medicaid programs

Responsibilities

*Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocols*Completes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review. *Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasks *Assign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.*Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.*Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.*Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs. *Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiries *Effective oral and written communication skills.*Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.*May perform activities that require evaluation or interpretation of information related to drug administration and treatments.*Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy Management*Ability to meet established deadlines timely, accurately and with a sense of urgency*Responsible for knowing and interpreting pharmacy and medical benefits.*Knowledge of Medical terminology and HIPAA regulations *Perform other duties as assigned.

Benefits

We're all about well-being, starting with yours.

Learn more about our employee benefits.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 13,000 employees - including more than 1200 providers and nearly 3,500 nurses.

Our health plan serves more than 640,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity

Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Offer DisclaimerThe compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs. Compensation decisions are dependent upon the facts and circumstances of each offer.Maximum OfferUSD $25.20/Hr.Employment Type: FULL_TIME