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Pharmacy Benefit Specialist

1 month ago

Rockledge, United States Health First Full time

*Position Summary * Apply proper authorization requirements and pharmacy benefits for all Health Plans’ in accordance with all State Statutes, Federal guidelines, and NCQA Standards where applicable. Prepare all authorization requests requiring clinical, coverage and/or organizational determinations for the clinical reviewer; which includes, all Formulary Exception, Prior Authorization and Administrative Authorization requests for both the pharmacy and medical benefit, as applicable. Assist pharmacists and case management in identifying opportunities, or deficiencies contributing to gaps in patient care, while assisting members with with transitions of care and disease management. *Primary Accountabilities * Apply proper authorization requirements to all prior authorization requests. Authorize services when all prior authorization criteria have been documented as met, as approved by the P&T Committee. Prepare requests requiring clinical review by a pharmacist and/or physician, which includes interpretation of all submitted medical records, lab results, office notes and provider supporting statement that are sent in support the request. Audit Pharmacy benefit adjudication system performance for speed and accuracy. Report any identified deficiencies. Collaborate with case management, sales teams, customer service, network pharmacies, and the PBM regarding pharmaceutical benefit questions and member referrals. Manage Patient Assistance Programs: Ensure HFHP does not pay for medications covered for our Medicare members by Drug Manufacturer Patient Assistance Programs by entering the appropriate edits in the claims adjudication system. Build, test and maintain the health plans formulary in pharmacy benefit adjudication software, ensuring round-the-clock operation. This includes having expert knowledge of plan design, multiple formularies, drug pricing, custom edits/messaging, and our physician network while making operational, customer service and financial decisions in the best interest of HFHP independently. Assist with resolution of all provider and/or member Rx & Medical Drug Benefit issues referred to pharmacy from customer service or sales teams. Coordinate appropriate administration for patients on infusion therapy. Coordinate appropriate dispensing specialty pharmacy for patients taking specialty drugs. Educate members and physicians on the prior authorization process and benefit application. Address all clinical issues or service issues with providers and/or members. MINIMUM QUALIFICATIONS Education and Work Experience: *Current FL Pharmacy Technician licensure with 3 years of Pharmacy Technician experience, (OR) a Bachelor’s Degree with 1 year of Managed Care, or Pharmacy Benefit Specialist experience. *Licensure: See above. Certification: None Required. Work Experience: Prior managed care experience or pharmacy experience. *Knowledge/Skills/Abilities: * Understand all the functions of a pharmacy benefit management company. Able to configure pharmacy benefit software and assume all functions performed by a full- service PBM company. Able to make operational, member service, and financial decisions in the best interest of HFHP with oversight and training. Ability to review and analyze clinical data with assistance and oversight. Knowledge of medical terminology required. Ability to review medical documentation and assist in making coverage determinations due to medical necessity. Ability to analyze data about medication ordering patterns. PREFERRED QUALIFICATIONS Education: *No additional education required. *Licensure: *No additional required. *Certification: National Pharmacy Technician Certification, or Pharmacy Technician Registration with the State of Florida. Work Experience: No additional required. Knowledge/Skills/Abilities: No additional required. PHYSICAL REQUIREMENTS Sedentary – Office Workers Majority of time involves sitting or standing; occasional walking, bending, stooping. Long periods of computer time or at workstation. Light work that may include lifting or moving objects up to 20 pounds with or without assistance. May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. Communicating with others to exchange information. Visual acuity and hand-eye coordination to perform tasks. Workspace may vary from open to confined; on site or remote. May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle. Job: *Pharmacy Organization: *HF Administrative Plan Inc Title: Pharmacy Benefit Specialist - Pharmacy Location: Florida - Brevard County-Rockledge Requisition ID: 072966

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