Spec Pharm Med Mgmt Tech - (US-CO-Denver - 80299)

Minimum Education: Tech School
Job Type: Full Time
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Anthem Blue Cross
is a proud member of the WellPoint family of companies and is one of California's oldest and largest health insurers. At Anthem, we are dedicated to our mission of improving the health of the people we serve through improved health of Californians and improved access to care. We believe the best health care coverage can actually help people stay healthy.

Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Works with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and scripted algorithms within scope of licensure. Primary duties may include, but not limited to: Reviews self or office-based injectables and claims edits. Under the oversight of a Registered Nurse conducts pre-certification, concurrent (if not associated with CM or DM triage), retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies, clinical guidelines, and pharmacology toolkit in compliance with department guidelines and consistent with the members eligibility, benefits and contract. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Skills:
Requires High School diploma; a Pharmacy Technician License with current licensure or certification in the appropriate state; up to 2 years clinical experience and recent customer services or utilization review experience; or any combination of education and experience, which would provide an equivalent background. Knowledge of the medical management process preferred. WellPoint is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2008 DiversityInc magazine

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