Pharmacy Process/Audit Tech I - 6008- Full Time- SHP- Telecommuter
- Health Plan
Shift Start Time:9 AM
Shift End Time:6 PM
Additional Shift Information:
Weekend Requirements:As Needed
Hourly Pay Range (Minimum - Midpoint - Maximum):$27.986 - $34.983 - $41.979
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
Conducts oversight and audit of pharmacy department and PBM activities to ensure compliance with department policies and procedures as well as state and federal regulations. Validates accuracy, completeness and timeliness for all commercial and Medicare pharmacy processes. Processes prior authorization review including intake, review, processing all determinations and member and provider notifications within the state and federal turnaround times and requirements as assigned. This includes working weekend shifts and holidays to ensure compliance with state and federal regulations.
- H.S. Diploma or Equivalent
- Experience in position requiring high levels of cooperation, collaboration, analysis, troubleshooting, and problem resolution.
- Experience in analyzing data, writing and editing a variety of communication materials, and interacting with senior level positions both internally and externally.
- Experience in a managed health care environment with some proficiency in Microsoft Office Suite including Word, Power Point, Excel.
- Bachelor's Degree In business or health care related field.
- California Pharmacy Technician License (TCH) - CA State Board of Pharmacy -PREFERRED
- Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board -PREFERRED
- Business research
Conducts research and analysis of paid drug claims, fee schedules, formularies, member and physician correspondence websites, and other plan materials on a daily basis to assess compliance to department policies and procedures, benefit designs sold, and both state and federal regulations. Maintains excellent records and paper trail of audits and findings. Prepares thorough reports with findings and makes recommendations, when appropriate, to both the senior pharmacy leadership and plan compliance officers.
Reviews all denied prescription claims for all lines of business on a daily basis and conducts outreach to enrollment, members, pharmacies, and physicians to coordinate next steps as appropriate.
Reviews bi-weekly new drug reports and provides recommendations for formulary additions for commercial plan formularies.
Prepares and/or edits communication pieces, including but not limited to drug formularies, member correspondence, reports, member materials, presentation materials, etc.
On behalf of senior management team members, may attend meetings and committees, communicate key message points, recommend involvement, and participate as appropriate or requested.
Synopsize and produce recommendations to managers succinctly yet thoroughly.
- Other duties
Participates in special projects and other duties as assigned. These may include, but are not limited to: work groups, proposals, audits and back-up support for other departments.
Completes ad hoc projects and duties as assigned.
Processes member reimbursement requests when needed.
- Prior authorization requests
Receives and processes prior authorization requests for medications from members, staff, physicians, and pharmacies within the required turnaround times set by Sharp Health Plan.
Receives prior authorization requests and evaluates requests using established guidelines.
Where guidelines do not exist, performs independent research using available resources to assess approval/non-approval of prior authorization requests.
Performs reviews and makes approval determinations for those requests that meet medical necessity criteria, appropriate utilization management and Sharp Health Plan criteria.
For requests that do not meet criteria for coverage or are benefit exclusions, prepares complete documentation supporting rationale for non-approval. Provides all documentation and rationale to clinical reviewer for final determination. Documentation includes rationale for denial, potential appropriate alternatives, proposed member and physician denial letter language. Denial letter language must follow DMHC and NCQA format and be clear and concise. Pharmacy technicians are not authorized to make denial determinations.
Sends out appropriate determination notifications within required timeframe.
Documents determinations and rationale in the software platform with 100% accuracy and timeliness.
Knowledge, Skills, and Abilities
- Knowledge of medical terminology, especially terms used in pharmacy practice, trade/generic drug names, drug pricing interpretation, metric system, CMS Part D requirements and CMS RXCUI nomenclature, state and federal pharmacy regulations is required.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
H.S. Diploma or Equivalent; Bachelor's Degree; Certified Pharmacy Technician (CPhT) - Pharmacy Technician Certification Board; California Pharmacy Technician License (TCH) - CA State Board of Pharmacy
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"After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it."
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