Pharmacy Prior Authorization Specialist
1 week ago
We are seeking a highly skilled Pharmacy Prior Authorization Technician to join our team at PSG Global Solutions Careers. As a Pharmacy Prior Authorization Technician, you will play a critical role in ensuring that our clients receive timely and accurate prior authorization decisions for pharmacy services.
Key Responsibilities- Conduct initial level medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the members benefit.
- Route cases directly to the pharmacist/medical director for final determination, as directed.
- Issue verbal and written member notification as required.
- Review and interpret prescription and medical benefit coverage across all lines of business including Medicare D to determine what type of prior authorization review is required.
- Document any relevant medication history and missing information to assist the pharmacist/nurse/physician in the review process.
- Develop and implement process improvement to increase efficiency in the review process for the clinical staff.
- Work with requesting providers, clinical pharmacists, and other internal staff, as appropriate, in determining whether specific case presentation meets the criteria for approval according to the medical or prescription drug policy and specific coverage criteria.
- Point out nuances that may not be readily apparent regarding the request.
- Contact pharmacies and physician offices as necessary to obtain clarification on prior authorization requests and drugs being billed through the point-of-sale system and/or medical claim system in order to optimize the member experience.
- Act as a lead troubleshooter for the pharmacy help desk, customer care and claim processors to coordinate pharmacy and/or medical claims with prior authorization information on file or needed for the member.
- Ensure care management system interfaces to claim processing system for claim payment.
- Perform system testing as required for upgrades and enhancements to the care management system.
- Act as a content expert for prior authorization intake for our customers, both internal and external.
- Serve as department subject matter expert for pharmacy and medical drug authorizations and coverage.
- Serve as lead liaison for the prior authorization process and its interface to the pharmacy and medical claim systems to troubleshoot.
- Triages issues to the appropriate department for resolution.
- Triages prior authorization workflow daily by rerouting cases, alerting clinical staff of time frame deadlines, monitoring work queues and keeping management aware of issues related to compliance mandated time frames for review completion.
- Provide phone coverage for incoming calls as required to support the UM process.
- Support medical and pharmacy drug pricing questions, and use drug lookup tools such as government sites, and other online resources.
- Maintain thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff with related inquiries.
- Perform unit specific workflow processes consistent with corporate medical & administrative policies, employer specific guidelines, and/or regulatory agencies.
- Produce, record, or distribute information for others.
- On a periodic basis, track and report department performance against benchmarks.
- Prepare and assist in handling correspondence.
- Assure accuracy and timeliness of processing.
- Participate in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services examples include Utilization Management, Quality Management and Case Management.
- Produce, at minimum, the team average medication prior-authorization, exception and medical necessity reviews submitted to the plan to determine coverage under the members benefit.
- Consistently demonstrate high standards of integrity by supporting the company's mission and values, adhering to the Corporate Code of Conduct, and leading to the company's values and beliefs.
- Maintain high regard for member privacy in accordance with the corporate privacy policies and procedures.
- Regular and reliable attendance is expected and required.
- Perform other functions as assigned by management.
- High school diploma with a minimum of two years experience in health-related field is required.
- Associates degree preferred.
- Pharmacy Technician certification (CPhT), LPN, Medical Assistant/Technologist background strongly preferred.
- Ability to work prolonged periods sitting at a workstation and working on a computer.
- Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
- Typical office environment including fluorescent lighting.
- Ability to work in a home office for continuous periods of time for business continuity.
- Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
- The ability to hear, understand and speak clearly while using a phone, with or without a headset.
-
Pharmacy Prior Authorization Specialist
2 weeks ago
Rochester, New York, United States PSG Global Solutions Careers Full timeJob SummaryWe are seeking a highly skilled Pharmacy Prior Authorization Technician to join our team at PSG Global Solutions Careers. As a Pharmacy Prior Authorization Technician, you will play a critical role in ensuring that our clients receive timely and accurate prior authorization decisions.Key ResponsibilitiesConduct initial level medication...
-
Rochester, New York, United States The University of Rochester Full timeAbout the Role:The University of Rochester seeks a highly skilled Patient Referral and Prior Authorization Specialist IV to join our team. As a key member of our healthcare team, you will be responsible for serving as the patient referral and prior authorization specialist, with oversight of data and compliance to enterprise standards and referral and prior...
-
Rochester, New York, United States Thrifty White Full timePharmacy Technician Long Term Care Job DescriptionThrifty White Pharmacy is seeking a skilled Pharmacy Technician to join our team in a long term care setting. As a Pharmacy Technician, you will play a vital role in providing exceptional pharmaceutical care to residents in nursing homes.Key Responsibilities:Assist pharmacists in processing medication orders...
-
Rochester, New York, United States Thrifty White Full timePharmacy Technician Long Term Care Job DescriptionThrifty White Pharmacy is seeking a skilled Pharmacy Technician to join our team in a long term care setting. As a Pharmacy Technician, you will play a vital role in providing exceptional pharmaceutical care to residents in nursing homes.Key Responsibilities:Assist pharmacists in processing medication orders...
-
Inpatient Pharmacy Specialist
4 weeks ago
Rochester, New York, United States University of Rochester Full timeGENERAL OVERVIEW:Utilizing clinical expertise and available resources, this role involves the approval of medication orders for patients receiving care at the medical facility. Supervises and actively participates in the compounding, preparation, and dispensing of medications for patients in compliance with all relevant state and federal pharmacy...
-
Clinical Pharmacy Specialist
3 weeks ago
Rochester, New York, United States The University of Rochester Full timeJob SummaryThe University of Rochester seeks a highly skilled Clinical Pharmacy Specialist to provide comprehensive clinical pharmacy services. This role is responsible for optimizing safe, effective, and cost-effective drug therapy in their area of practice.Key ResponsibilitiesParticipate in multidisciplinary teams to optimize patient careDevelop and...
-
Outpatient Pharmacy Specialist II
4 weeks ago
Rochester, New York, United States University of Rochester Full timeGENERAL OVERVIEW:Utilizing clinical expertise and available resources, the pharmacist is responsible for dispensing medications to patients in an outpatient pharmacy setting. Supervises and actively participates in the compounding, preparation, and distribution of medications for patients, ensuring compliance with all relevant state and federal pharmacy...
-
Outpatient Pharmacy Specialist II
4 weeks ago
Rochester, New York, United States University of Rochester Full timeGENERAL OVERVIEW:Utilizing clinical expertise and available resources, the pharmacist is responsible for dispensing medications to patients in an outpatient pharmacy setting. This role includes overseeing and actively participating in the compounding, preparation, and distribution of medications in compliance with all relevant state and federal pharmacy...
-
Pharmacy Specialist in Rome, NY
1 month ago
Rochester, New York, United States Soliant Full timeJob OverviewWe are seeking a dedicated Pharmacy Specialist with a minimum of 1+ years of experience in the pharmacy field. This role involves managing pharmacy operations in a retail or long-term care environment.Key Responsibilities:Distributing medications as prescribed by healthcare professionals.Providing expert advice to customers regarding medication...
-
Outpatient Pharmacy Specialist II
1 month ago
Rochester, New York, United States University of Rochester Full timeGENERAL OVERVIEW:Utilizing clinical expertise and available resources, the pharmacist is responsible for dispensing medications to patients in an outpatient pharmacy setting. This role includes overseeing and actively participating in the compounding, preparation, and distribution of medications, ensuring compliance with all relevant state and federal...
-
Pharmacy Delivery Specialist
2 weeks ago
Rochester, New York, United States CVS Health Full timeJob SummaryWe are seeking a skilled and detail-oriented Pharmacy Delivery Specialist to join our team at CVS Health. As a key member of our delivery team, you will be responsible for delivering prescription orders and products to customers on a predetermined route and schedule.Key ResponsibilitiesDeliver prescription orders and products to customers in a...
-
Pharmacy Technician
2 weeks ago
Rochester, New York, United States Walgreens Full timeJob SummaryWe are seeking a highly skilled Certified Senior Pharmacy Technician to join our team at Walgreens. As a key member of our pharmacy team, you will play a critical role in delivering exceptional customer service and ensuring the smooth operation of our pharmacy department.Key ResponsibilitiesProvide exceptional customer service by greeting...
-
Pharmacy Technician
4 days ago
Rochester, New York, United States Walgreens Full timeJob Description:In accordance with state and federal regulations, assists the pharmacist in the practice of pharmacy, under direct supervision. Performs various Pharmacy Department duties in accordance with Company policies and procedures.Responsibilities:Uses pharmacy systems to obtain patient and drug information and process prescriptions.Assists with and...
-
Pharmacy Technician
5 days ago
Rochester, New York, United States Walgreens Full timeJob Description:As a Pharmacy Technician at Walgreens, you will play a vital role in providing exceptional patient care and service. Our pharmacy technicians are the face of our company, interacting with customers and developing strong relationships with our patients.We are seeking a highly motivated and detail-oriented individual to join our team as a...
-
Pharmacy Technician Specialist
48 minutes ago
Rochester, New York, United States SpecialtyRX Full timeJob OpportunityWe are seeking a skilled Pharmacy Technician to join our team at SpecialtyRx in East Rochester, NY.As a Pharmacy Technician, you will play a vital role in supporting our pharmacy operations, ensuring the accuracy and efficiency of medication dispensing, and providing exceptional customer service to our clients.Key Responsibilities:Assist...
-
Pharmacy Technician Specialist
1 week ago
Rochester, New York, United States Rochester Regional Health Full timeAbout the RoleWe are seeking a skilled Pharmacy Technician to join our team at Rochester Regional Health. As a Pharmacy Technician, you will play a vital role in ensuring the safe and efficient preparation and delivery of medications to our patients.Key ResponsibilitiesPrepare and deliver medications to patients, ensuring accuracy and attention to...
-
Inpatient Pharmacy Specialist
1 month ago
Rochester, New York, United States Highland Hospital Full timeJob Title:Clinical Staff PharmacistDepartment:Pharmacy ServicesPosition Overview:Under the supervision of the Director of Clinical Pharmacy Services and the Director of Pharmacy Operations, the Clinical Staff Pharmacist plays a crucial role in enhancing patient medication management through comprehensive clinical pharmacy services. This position involves...
-
Pharmacy Department Assistant
4 days ago
Rochester, New York, United States Walgreens Full timeJob SummaryWe are seeking a highly skilled and experienced Senior Pharmacy Technician to join our team at Walgreens. As a Senior Pharmacy Technician, you will play a critical role in assisting pharmacists in the practice of pharmacy, ensuring the accuracy and efficiency of prescription dispensing, and providing exceptional customer service to our...
-
Inpatient Pharmacy Specialist
1 month ago
Rochester, New York, United States Highland Hospital Full timeJob Title:Clinical Staff PharmacistDepartment:Pharmacy ServicesPosition Overview:Under the supervision of the Director of Clinical Pharmacy Services and the Director of Pharmacy Operations, the Clinical Staff Pharmacist is responsible for enhancing patient medication management through comprehensive clinical pharmacy services. This role involves...
-
Inpatient Pharmacy Specialist
1 month ago
Rochester, New York, United States Highland Hospital Full timeJob Title:Clinical Staff PharmacistDepartment:Pharmacy ServicesPosition Overview:Under the supervision of the Director of Clinical Pharmacy Services and the Director of Pharmacy Operations, the Clinical Staff Pharmacist plays a crucial role in enhancing patient medication management through the delivery of extensive clinical pharmacy services. This position...
