Actalent
JOB PURPOSE:* The Pharmacy Services Technician is a corporate-wide technical support resource for pharmacy benefit, reimbursement, and other drug use issues which do not require clinical judgment. This function assists the Clinical Pharmacy Consultants and Pharmacy Services staff with formulary-related operations and other operational processes which require knowledge and experience with pharmaceuticals.
ESSENTIAL FUNCTIONS:*
Performs all duties as described in this document unless doing so would require clinical judgement. In any situation in which clinical judgment is necessary, the Pharmacy Services Technician will seek assistance from appropriate medical personnel. Appropriate medical personnel will be available for support during normal business hours.
Responds to non-clinical pharmacy issues from providers, pharmacy services staff, case managers, preauthorization nurses, ENCC personnel, and government programs personnel and customer service. These pharmacy issues include formulary drug coverage, appeal and reconsideration claim status, and pricing for drug claims.
Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals.
Prepares reconsideration requests for Clinical Pharmacy Consultant review by obtaining and organizing appropriate documentation, including, but not limited to medical chart notes/reports and medication profiles.
Communicates (orally and by written documentation) information and determinations to providers and members as necessary.
Obtains and organizes drug utilization data, including patient specific and population based data, in a manner which facilitates clinical review and decisions by Clinical Pharmacist Consultants. Organizing data includes but is not limited to sorting drugs into appropriate therapeutic and generic categories.
Assists with auditing and investigations of medication-related claims, cases, and providers to identify misuse of medications, misuse of (Regence HMO Oregon) resources, substance abuse, and erroneous and fraudulent billing practices.
Investigates and organizes workflow for claims referred to Pharmacy Services for review and allowable determination (misc. J codes, providers on review, reconsiderations).
Supports wellness and disease state management programs for Pharmacy Service and corporately which contribute to NCQA accreditation and ongoing quality improvement.
Contributes to and supports the corporation’s quality initiatives through process improvement teams and by encouraging team and individual contributions toward the corporation’s quality improvement efforts.
Conducts business in compliance with company’s Code of Business Conduct, immediately reports violations of the code to management, human resources, internal audit, legal of the compliance officer; and helps in investigating alleged wrongdoing.
Skills & Qualifications:*
MUST HAVES:*
Candidates MUST reside in one of the four states in which Cambia operates: Oregon, Washington, Idaho or Utah. ** BE SURE TO INCLUDE CANDIDATE LOCATION IN SUBMISSION COMMENTS OR RESUME. **
Pharmacy Technician License (can be perm or temp)
3-5 years of experience as a pharmacy technician in a retail, hospital, or other licensed pharmacy setting OR Pharm Tech Certification
Experience with health insurance and/or prescription benefits
Knowledge of medical terminology and healthcare coding systems (ICD-9, CPT, and HCPCS)
Experience with pharmaceutical products, including orals, injectables, infusion products, and chemotherapy
Experience with health insurance and/or prescription benefits
Ability to perform pharmaceutical calculations
Computer skills and proficiency with Microsoft Office (Word, Excel, Outlook)
Ability to type 30-60 WPM
About Actalent:
Actalent connects passion with purpose. Our scalable talent solutions and services capabilities drive value and results and provide the expertise to help our customers achieve more. Every day, our experts around the globe are making an impact. We’re supporting critical initiatives in engineering and sciences that advance how companies serve the world. Actalent promotes consultant care and engagement through experiences that enable continuous development. Our people are the difference. Actalent is an operating company of Allegis Group, the global leader in talent solutions. The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
To apply for this job please visit careers.actalentservices.com.