Nursing, Pharmacy,
2 weeks ago
The main function of Pharmacy Services is to provide efficient and accurate responses to external customers (physicians, office staff, pharmacy providers, members and brokers) and internal team members. Resolves outpatient pharmacy benefit coverage (inclusion/exclusion), prescription claim problems, communicates drug formulary guidelines including drug formulary alternatives, prior authorization criteria and group/member eligibility problems. Researches and solves administrative review and consumer affairs issues.
Job Responsibilities:
• Under general supervision, coordinates, assists in and supports implementation of procedures and guidelines for the drug prior authorization program for the outpatient Pharmacy Benefit.
•Communicates with the physician, physician's office staff, medical management and other Cross team members to assist with accurate and efficient resolution of prior authorization requests
•Assists in providing formulary alternatives and communicates prior authorization criteria, and discusses pharmacy benefit coverage inclusions/exclusions when required
•Interfaces in a courteous and professional manner with physicians, physician office staff, contracted pharmacists, patients, and other Cross team members during the prior authorization process
•Provides drug usage history and other pertinent pharmacy benefit related computer searches for pharmacists and Medical Director to assist in case specific reviews and drug evaluations.
•Assists pharmacists with drug utilization review programs, NCQA QI programs or other assigned projects
•Communicates prior authorization criteria, pharmacy benefit coverage and formulary alternatives to physician, physician office staff, medical management staff, sales, member/customer services
•Assists in research and resolution of physician inquiries and grievances
•Provides essential clinical information to BSC Member Services, Administrative Review Department and Consumer Affairs to resolve Member inquires and grievances
Education and Experience:
•Currently in training or recently completed training but has not consistently reached production/quality standards
• - years' experience required.
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