Role Description

Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Recommendations will be based on an in-depth understanding of specific specialty medications and industry guidelines, on both pre- and post-service requests. Coordinates with operations, clinical, medical, reporting and other internal departments as needed.

Responsibilities

• Reviews pertinent patient information and checks appropriateness using clinical criteria.
• Makes approval recommendations on all services that meet clinical review criteria.
• Refers all cases not meeting clinical criteria to pharmacist clinical reviewer.
• Practices and maintains the principles of utilization management by adhering to the company policies and procedures.
• Upholds clinical integrity of pharmaceutical solutions by participating in on-going training programs to ensure quality performance in compliance with applicable standards and regulations.
• Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client.
• Assists with the documentation and implementation of both written and verbal communications to physicians/prescribers.
• Available for consultation in pharmacy related questions to resolve claims submission related to medication edits.
• Contacts physicians/prescribers to obtain pertinent clinical history/information.
• Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan's required timeframes.
• Regularly reviews and monitors information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data.
• Supports Intake call volume and order entry if necessary.
• Determines eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enters approvals or denials in the system.
• Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies.
• Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary.
• Other duties as assigned.

Qualifications

• Associate's degree in or equivalent combination of education and/or work experience in similar field; HS diploma or GED is required.
• 2+ years of Pharmacy Experience.
• CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy.
• Must be eligible to work in the United States without the need for work visa or residency sponsorship.

Requirements

• Must have an active pharmacy technician licensure or registration in accordance with state requirements.
• If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT).
• In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT).
• Minimum of 2 years of pharmacy experience without a Bachelor's degree OR 2 years of pharmacy experience with a Bachelor's degree in Science, Health, Medical or related field.
• Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.
• Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.
• Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing.
• Strong team orientation with respect for all members.
• Excellent verbal and written communications skills.
• People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position.
• Analytic skills which can translate into practical and pragmatic recommendations.
• In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology.

Preferred Qualifications

• Oncology pharmacy or other clinical pharmacy experience.
• 4 years of pharmacy experience.

Benefits

Potential pay for this position ranges from $23.08 - $37.02 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.

Company Description

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer.