Highmark Health Pharmacy Coordinator in Pittsburgh, Pennsylvania
I. GENERAL OVERVIEW:
The Pharmacy Coordinator provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings. This position responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. Will interact with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.
II. ESSENTIAL RESPONSIBILITIES:
- Communicate effectively
With physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner
Interact with staff to implement processes and problem solves.
- Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department to include but not limited to:
Prioritization of requests for drug authorizations or denials
Review of prior authorization criteria for drug products
Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity
Ensure call center turn around time requirements associated with DPW/CMS regulations are adhered to
- Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override
Search member claim history profile and recommend formulary alternatives wherever feasible
Contact physician network provider to obtain necessary and/or additional information when necessary
Consult with staff clinical pharmacist for guidance and assistance as necessary
- Document all authorizations and denials completely and accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member
Populate all authorization and denial information fields within the OnBase information system
Enter all authorizations into the Argus IPNS information system to allow claim adjudication
- Complete other assigned duties as specified
Identify and report improper coordination of benefit billing practices through paid clams review
Participate as pharmacy representative in onsite member appeals and grievances sessions
Serve as a resource for technical staff
Other duties as assigned or requested.
High school diploma or GED
Experience in pharmacy prescription claims processing/submission/payment.
Pharmacy technician certification certificate
Experience working in a managed care medication formulary management environment
Working knowledge of retail pharmacy and/or third party prescription procession
Strong background and understanding of medications and formulary terminology
Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation.
Knowledge, Skills and Abilities
Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
Excellent interpersonal, communication and attentive listening skills
Strong organizational skills, detail oriented
Demonstrated excellence in communication skills
Demonstrated ability to work well with others
Demonstrated ability to work in a fast paced, multi-task environment
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No □ Yes □
If yes, indicate the number of direct reports:
V. WORK ENVIRONMENT
Is Travel Required?
No x Yes □
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled