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Pharmacy Utilization Management Specialist

2 months ago

Canton, United States Ignyte AI Full time
Job DescriptionJob Description

Job Summary

Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management (UM) Specialist is responsible for setting up, reviewing, and processing prior authorization cases in the various applications for coverage determination requests. The specialist ensures timely disposition of reviews for established timeframes.

Key Responsibilities/Duties – what you will be doing

  • Performs full case set up from fax, ePA, phone and email prior authorization requests
  • Upon case set up, a full case review is performed ensuring all applicable regulatory and accreditation requirements and turnaround times are met
  • Documents all relevant case notes for PAs (prior authorizations) requiring additional review by a pharmacist or medical director
  • The Pharmacy Utilization Management Specialist will run test claims for approved authorizations and reach out to members and providers as necessary
  • Communicates with providers via department phone queue to process phone PAs and resolve provider inquiries
  • Additional tasks include performing daily quality checks to ensure compliance, managing the Pharmacy UM team email box, responding to provider inquiries, managing electronic prior authorization (ePA) requests, submitting process improvements, among others
  • Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Director
  • Other duties and projects as assigned.

Qualifications – what you need to perform the job

Education, Certification and Licensure

  • High School Diploma or GED
  • Associate's degree in Healthcare, Nursing, or a related area or equivalent experience
  • Certified Pharmacy Technician (CPhT)

Experience (minimum years required):

  • Minimum of 3 years of pharmacy experience, preferably in managed care/PBM setting
  • Software/Database experience - RxClaims, PAHub, CAS, or MHK is preferred

Skill Requirements

  • Proficient in MS Office - Excel, Word, and PowerPoint Preferred
  • Ability to prioritize work when processing pharmacy PA requests per guidelines and within specific turnaround times
  • Ability to process high volumes of requests with great accuracy
  • Attention to detail and the ability to handle multiple demands, as well as balance multiple priorities in a fast-paced environment
  • Good working knowledge of medical terminology
  • Must be able to work independently, and as part of a team. Regular interface with various levels of staff and management is required.
  • Must be able to exercise appropriate judgement as necessary, following all rules and regulations where required

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8117