Initial Review Pharmacy Technician (Remote)

About the position

As an Initial Review Pharmacy Technician at Prime Therapeutics, you will play a crucial role in our medical and pharmacy management initiatives, which are essential for achieving our revenue goals and operational objectives. Your primary responsibility will be to execute utilization management programs on behalf of our health plan and payor customers. This will involve utilizing your clinical knowledge to assess a specific list of managed medications across all health plans, with additional training provided for each medication and therapeutic class. You will be engaged in reviewing both prospective and retrospective requests for therapeutic appropriateness, applying sound clinical criteria to make informed recommendations. In this role, you will be responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather necessary clinical information that will aid in determining medication reimbursement. Your recommendations will be based on a comprehensive understanding of specialty medications and industry guidelines, addressing both pre- and post-service requests. You will also coordinate with various internal departments, including operations, clinical, medical, and reporting, to ensure seamless execution of your responsibilities. Your daily tasks will include reviewing pertinent patient information, checking the appropriateness of requests using clinical criteria, and making approval recommendations for services that meet these criteria. You will refer cases that do not meet clinical criteria to a pharmacist clinical reviewer. Additionally, you will conduct Program Integrity Audits, assist in documentation and communication with prescribers, and provide consultation on pharmacy-related questions to resolve claims submission issues. Your role will also involve monitoring pended claims and supporting intake call volume and order entry as needed. You will determine eligibility for medication reimbursement based on established clinical criteria and document all communications electronically. This position requires a commitment to maintaining the clinical integrity of pharmaceutical solutions and participating in ongoing training programs to ensure compliance with applicable standards and regulations. You will be expected to uphold the principles of utilization management and provide optimum customer service through professional communication while adhering to required timeframes.

Responsibilities
? Review pertinent patient information and check appropriateness using clinical criteria.
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? Make approval recommendations on all services that meet clinical review criteria.
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? Refer all cases not meeting clinical criteria to pharmacist clinical reviewer.
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? Practice and maintain the principles of utilization management by adhering to company policies and procedures.
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? Uphold clinical integrity of pharmaceutical solutions by participating in ongoing training programs.
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? Conduct Program Integrity Audits including outreach and review of medical records.
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? Assist with documentation and implementation of communications to physicians/prescribers.
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? Contact physicians/prescribers to obtain pertinent clinical history/information.
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? Provide optimum customer service through professional communication.
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? Regularly review and monitor information on pended claims identified as outliers.
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? Support intake call volume and order entry if necessary.
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? Determine eligibility for medication reimbursement based on established clinical criteria.
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? Electronically document communications with physicians, their staff, cardholders, and pharmacies.
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? Escalate medical exception requests to nurse, pharmacist or physician when necessary.

Requirements
? Must have an active pharmacy technician licensure or registration in accordance with state requirements.
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? If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or registration and an active national certification (e.g., PTCB or ExCPT).
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? Minimum of 2 years of pharmacy experience without a Bachelor's degree OR 2 years of pharmacy experience with a Bachelor's degree in Science, Health, Medical or related field.
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? Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.
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? Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.
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? Comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems.
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? Strong team orientation with respect for all members.
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? Excellent verbal and written communications skills.
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? Analytic skills which can translate into practical and pragmatic recommendations.
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? In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology.

Nice-to-haves
? Oncology pharmacy or other clinical pharmacy experience.
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? 4 years of pharmacy experience.

Benefits
? Competitive pay range from $22.84 - $34.25 based on experience and skills.
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? Comprehensive benefits package including health insurance, dental insurance, and retirement plans.
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? Opportunities for professional development and training.
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? Flexible work environment with remote work options.

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