Experience Inc. Jobs

Company :

Allegheny Health Network

Job Description :

JOB SUMMARY

This position supports the network centralized prior authorization department. Coordinates and administers the effective and efficient processing of the pharmacy benefits prior authorization process, ensuring that pharmacy benefits are administered in accordance with all regulatory agency requirements

ESSENTIAL RESPONSIBILITIES

• Reviews pharmacy utilization management (UM) coverage requests and prepares such cases for clinical review by a pharmacist and/or medical director when required. (20%)

• Within the context of the request, applies plan-specific benefits to each case appropriately, summarizes pertinent facts, and cites applicable internal policies and guidelines. (20%)

• Resolves non-clinical issues independently and acts as a liaison between our customer and provider-facing teams and the Corporate Pharmacy Department. (20%)

• Maintain regulatory compliance and resolves all cases within predetermined timeframes. (15%)

• Responsible for all preauthorization entries into applicable databases (i.e. internal medical claims systems, PBM pharmacy systems) to ensure swift and appropriate payment of services deemed medically necessary. (20%)

• Engages in member and provider outreach to resolve non-clinical issues such as appeal initiation requests, processing errors, and fulfilling notification requirements among others. (5%)

• May perform other non-clinical duties as required by management and department needs.

EXPERIENCE

Required

• 2 years of experience as a Pharmacy Technician in a hospital, retail, or managed care setting

Preferred

• None

SKILLS

• Strong knowledge of medical and pharmaceutical terminology

• Strong verbal and written communication skills

• Well organized, paying close attention to detail

• Ability to identify and resolve problems

• Ability to handle multiple priorities in a timely manner

• Strong interpersonal skills

• Ability to work independently or in a team environment

• Customer oriented

• Proficient with Microsoft Office products (i.e. Word, Excel, PowerPoint, etc.)

EDUCATION

Required

• Associate degree

Preferred

• None

LICENSES or CERTIFICATIONS

Required

• Certified Pharmacy Technician (CPhT) from Pharmacy Technician Certification Board

Preferred

• None

Language (Other than English) :

None

Travel Requirement:

0% - 25%

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job 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. _

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. 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.

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Req ID: J250779