Job Details

Works under general supervision and answers calls from physician and pharmacy providers through pharmacy hotline. Assist in administering prior authorizations according to established guidelines and assists Clinical Pharmacists in case review process. Actively participate in physician education and outreach program and perform claims analysis for drug utilization review (DUR), fraud, abuse, and over-utilization.

Job Description

Summary
Works under general supervision and answers calls from physician and pharmacy providers through pharmacy hotline. Assist in administering prior authorizations according to established guidelines and assists Clinical Pharmacists in case review process. Actively participate in physician education and outreach program and perform claims analysis for drug utilization review (DUR), fraud, abuse, and over-utilization.

Job Duties

• Able to work in a constant state of alertness and safe manner
• Assist department in reaching call center goals based on standards of productivity (percent of calls answered within 30 seconds, percent of abandoned calls).
• Assist department in reaching call center goals based on standards of quality (providing accurate information to physicians and pharmacies)
• Maintain knowledge of different pharmacy benefit packages under Medicaid and Medicare to be communicated to providers and other departments
• Assist Clinical Pharmacists in responding to physician and pharmacy providers’ telephone calls, to provide safe and effective formulary alternatives, resolve processing errors (i.e. eligibility, plans limits exceeded, national drug code (NDC) not covered, refill too soon, etc.).
• Assist Clinical Pharmacists in reviewing clinical cases including researching previous medication history, obtaining additional information as it pertains to the case, notifying physician’s office of approval and/or denial of prior authorization request, generating letters for approved medication requests, and expedite prior authorization requests.
• Interact with other departments including Member Relations, Special Needs Unit, Complaints and Grievances, Disease Management, and Utilization Management; assisting in resolving pharmacy issues.
• Conduct clinical DUR on pharmacy claims and make recommendations for recipient restriction program.
• Provide ideas and suggestions to help improve quality and flow of pharmacy department.
• May perform other duties as assigned.

Minimum Qualifications

• High School Diploma/GED
• 1 year of’ experience in pharmacy.
• Familiar with a managed care and delegated pharmacy services
• Excellent written and oral communication skills
• Self-motivated and a team player.
• Proficient in Excel and relational databases such as MHS, CIC, DST, Macess
• CPhT - Certified Pharmacy Technician - Pharmacy Technician Certification Board

Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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