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The primary purpose of the job is to: Reviews physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria. Forwards initial denials to appropriate queue for further review. Generates notification letters to members and physicians on approved and denied requests. Handles calls and correspondence from providers; responds to inquiries, complaints and reconsiderations. Documents calls in inquiry tracking system. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Receives escalated calls that cannot be clinically resolved by 1st level intervention. Researches, resolves and responds to provider clinical inquiries. Supports Fraud and Abuse program system oversight. Communicates any suspected fraud discovered by the contact center staff. Recommends course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards. Serves as second-line contact for all internal pharmacy related issues. Functions as clinical liaison between internal staff and pharmacy network participants. Ensures internal changes that may affect network services are reflected in the claims processing system. Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review. Works with appropriate individuals/vendors to facilitate compliance. Responds to and drafts correspondence to physicians regarding requests on Drug Formulary. Responds to telephone inquiries from physicians, other healthcare professionals and members regarding select drug information. Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization. Assures compliance to PerformRx policies and procedures regarding pharmacy protocol. Participates in various Pharmacy-related projects. Performs appropriate research, analysis and generates findings report. Submits recommendation to Manager for review and input. May assist in implementation and/or coordination of project changes. Supports the MTM/DTM program through activities which may include the following: Performs medication therapy reviews to identify medication related problems, performs interactive consultations and makes recommendations/interventions for members and providers, appropriately documents all pharmacotherapy interventions, responds to questions and provides clarification for requests generated in regards to MTM/DTM programs. Has attended or attends MTM/DTM certificate training. Complies with URAC/CMS standards and regulation for DTMP. Performs other related duties and projects as assigned. Attends required training on an annual basis. Job Specific Competencies Knowledge in pharmacy practices, procedures and precedents; ability to read and understand pharmaceutical information Proven ability to write technical articles, position papers and draft presentation documents Strong clinical knowledge and the ability to make sound clinical judgments Strong research and analytical ability Ability to extrapolate data and present research results Ability to handle multiple priorities and projects independently Ability to present ideas, findings in a classroom setting Excellent interpersonal and organizational skills Excellent oral and written communication skills Proficient PC skills in a windows based environment Ability to quickly troubleshoot concerns of providers and handle escalated situations Demonstrates knowledge of Federal & State laws/regulations regarding provisions of pharmaceutical ser
Skills:
Current pharmacy license, Commonwealth of Pennsylvania preferred. Pharm D. preferred. 2 years pharmacy experience preferred. Previous experience in managed care environment preferred. MTM/DTM certificate training preferred
The primary purpose of the job is to: Reviews physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria. Forwards initial denials to appropriate queue for further review. Generates notification letters to members and physicians on approved and denied requests. Handles calls and correspondence from providers; responds to inquiries, complaints and reconsiderations. Documents calls in inquiry tracking system. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Receives escalated calls that cannot be clinically resolved by 1st level intervention. Researches, resolves and responds to provider clinical inquiries. Supports Fraud and Abuse program system oversight. Communicates any suspected fraud discovered by the contact center staff. Recommends course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards. Serves as second-line contact for all internal pharmacy related issues. Functions as clinical liaison between internal staff and pharmacy network participants. Ensures internal changes that may affect network services are reflected in the claims processing system. Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review. Works with appropriate individuals/vendors to facilitate compliance. Responds to and drafts correspondence to physicians regarding requests on Drug Formulary. Responds to telephone inquiries from physicians, other healthcare professionals and members regarding select drug information. Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization. Assures compliance to PerformRx policies and procedures regarding pharmacy protocol. Participates in various Pharmacy-related projects. Performs appropriate research, analysis and generates findings report. Submits recommendation to Manager for review and input. May assist in implementation and/or coordination of project changes. Supports the MTM/DTM program through activities which may include the following: Performs medication therapy reviews to identify medication related problems, performs interactive consultations and makes recommendations/interventions for members and providers, appropriately documents all pharmacotherapy interventions, responds to questions and provides clarification for requests generated in regards to MTM/DTM programs. Has attended or attends MTM/DTM certificate training. Complies with URAC/CMS standards and regulation for DTMP. Performs other related duties and projects as assigned. Attends required training on an annual basis. Job Specific Competencies Knowledge in pharmacy practices, procedures and precedents; ability to read and understand pharmaceutical information Proven ability to write technical articles, position papers and draft presentation documents Strong clinical knowledge and the ability to make sound clinical judgments Strong research and analytical ability Ability to extrapolate data and present research results Ability to handle multiple priorities and projects independently Ability to present ideas, findings in a classroom setting Excellent interpersonal and organizational skills Excellent oral and written communication skills Proficient PC skills in a windows based environment Ability to quickly troubleshoot concerns of providers and handle escalated situations Demonstrates knowledge of Federal & State laws/regulations regarding provisions of pharmaceutical ser
Skills:
Current pharmacy license, Commonwealth of Pennsylvania preferred. Pharm D. preferred. 2 years pharmacy experience preferred. Previous experience in managed care environment preferred. MTM/DTM certificate training preferred
V R Della Infotech Inc
