Medical Staff Services Coordinator

3 weeks ago

Harrisburg, Pennsylvania, United States Highmark Health Full time

Job Summary:

This role provides front-line staff guidance, ensuring effective and efficient delivery of Pharmacy call center services. The incumbent serves as the first line reviewer in monitoring and ensuring adherence to the health plan's state and federal multiple drug benefit design offerings.

The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable, and infusion medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, the incumbent clearly defines the medical necessity of non-formulary and prior authorization medication exception requests.

The incumbent interacts with pharmacy network providers to evaluate, educate, and/or assist in addressing denied point-of-sale prescription claim transitions and coordination of benefits practices/procedures. The incumbent communicates effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful, and timely manner.

The incumbent interacts with staff to implement processes and problem-solve. The incumbent ensures adherence to call center turn-around time requirements associated with DHS/CMS regulations.

The incumbent takes necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization, or claim override. The incumbent searches member claim history profiles and recommends formulary alternatives wherever feasible.

The incumbent contacts physician network providers to obtain necessary and/or additional information when necessary. The incumbent consults with staff clinical pharmacists for guidance and assistance as necessary.

The incumbent documents all authorizations and denials completely, accurately, and in accordance with timelines as defined by state and federal regulations to ensure appropriate notification issuance to prescribing physicians and impacted members.

The incumbent populates all authorization and denial information fields within the MedHok information system. The incumbent enters all authorizations into the CVS PBM information system to allow claim adjudication.

The incumbent participates as a pharmacy representative in onsite member appeals and grievances sessions. The incumbent serves as a resource for technical staff.

Experience in pharmacy prescription claims processing/submission/payment is required. Pharmacy technician certification is also required. Working knowledge of retail pharmacy and/or third-party prescription processing is necessary.

The incumbent must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states. Excellent computer skills, including working knowledge of Microsoft Outlook, Word, and OnBase, are required.

Compliance Requirement:

This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.

In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity, or any other category protected by applicable federal, state, or local law.

Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status, or disability.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity

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