Clinical Pharmacy Review Specialist

About the role

Build your Career. Make a Difference. Presbyterian is hiring a skilled Clinical Pharmacy Review Specialist to join our team. Type of Opportunity: Full time Job Exempt: No Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)

Responsibilities

• The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.
• Some key responsibilities include:
• Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocols
• Completes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasks
• Assign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.
• Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.
• Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.
• Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs.
• Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiries
• Effective oral and written communication skills.
• Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.
• May perform activities that require evaluation or interpretation of information related to drug administration and treatments.
• Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy Management
• Ability to meet established deadlines timely, accurately and with a sense of urgency
• Responsible for knowing and interpreting pharmacy and medical benefits.
• Knowledge of Medical terminology and HIPAA regulations
• Perform other duties as assigned.

Requirements

• GED or High School diploma is required.
• Certified Pharmacy Technician-PTCB is required
• Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred
• Retail Pharmacy experience preferred
• Managed care customer service experience preferred
• Drug Information skills
• Experience with Medicare Part D insurance and Medicaid programs
• All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Wellness
• Why work at Presbyterian?
• As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
• About Presbyterian Healthcare Services
• Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
• AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
• We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services

Benefits

Additional Information

Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237 Compensation Pay Range: Minimum Offer $18.33 Maximum Offer $27.25 Now Hiring: Clinical Pharmacy Review Specialist

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