Lead Pharmacy Review Specialist Job at Presbyterian Healthcare Services
Overview:
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days Qualifications:
Education:
Essential:
Credentials:
Essential:
Responsibilities:
We offer more than the standard benefits!
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
Why work at Presbyterian?
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 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.
About Our Regional Delivery System
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
The Clinical Pharmacy Review Specialist Lead works under the direct supervision of a Clinical Pharmacist, and assists in the workflow direction of Clinical Pharmacy Review Specialists and ensures that the operations of the Pharmacy Services call center and workflow of the daily Prior Authorization process are met. The lead coordinates ongoing monitoring of the daily workflow and productivity to ensure all systems are available and performing as expected and that processes and procedures are followed to ensure compliance with department guidelines, Federal and State regulations and Presbyterian performance standards.
Orients, trains, assigns work, maintains work schedules and evaluates performance of staff in keeping with established policies, procedures, standards of practice and scope of pharmacy services department. Assist in the hiring, on boarding, training and on-going coaching and development of the Clinical Pharmacy Review Team.
Be fully knowledgeable and thoroughly familiar with the nature and duties of every Technician staff position in the department including procedures, policies and operations. Work closely with Pharmacy Benefit Analysts and System Specialists regarding claims processing issues and pharmacy applications to ensure that the Pharmacy department and staff are maximizing the resources available to successfully identify and manage issues or failures that may impact daily operations.
Orients, trains, assigns work, maintains work schedules and evaluates performance of staff in keeping with established policies, procedures, standards of practice and scope of pharmacy services department. Assist in the hiring, on boarding, training and on-going coaching and development of the Clinical Pharmacy Review Team.
Be fully knowledgeable and thoroughly familiar with the nature and duties of every Technician staff position in the department including procedures, policies and operations. Work closely with Pharmacy Benefit Analysts and System Specialists regarding claims processing issues and pharmacy applications to ensure that the Pharmacy department and staff are maximizing the resources available to successfully identify and manage issues or failures that may impact daily operations.
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days
- GED or High School diploma is required.
- Clinical Pharmacy Review Specialist II is a pre-requisite or 1 year Pharmacy Service Team (RxCSC) experience.
- Experience with Medicare Part D insurance and Medicaid programs.
Education:
Essential:
- High School Diploma or GED
Credentials:
Essential:
- Certified Pharmacy Technician-PTCB
- Assist the Pharmacy Clinical Manager on all escalated issues.
- Pharmacy Technician Lead will serve as a trainer and or mentor for Pharmacy Benefits Technician I and II.
- Ability to develop workflow guidelines using reference documents, policies and procedures and desktop procedures to maximize productivity and standardize the prior authorization workflow.
- Manage daily activity of the Pharmacy prior authorization system and Pharmacy Helpdesk applications to ensure adequate staffing to meet all customer needs, maintain service levels and ensure regulatory requirements are met.
- Assist in activities and functions of pharmacy technicians and support personnel in assigned areas of the department.
- Audit the Technical review of prior authorization (drug and utilization management) requests within the pharmacy claims processing system that includes coverage determination request, chart notes, and/or relevant clinical information based on defined criteria within the scope of approved protocols and decision trees.
- Ability to audit completed prior authorization requests to ensure that established procedures were followed and input information was accurately applied according to the members benefit.
- Ability to communicate information effectively with internal departments, members, providers, pharmacists and pharmacy staff to identify and resolve complex pharmacy claim rejections or medical claim denials.
- Ability to provide guidance to Pharmacy Technicians and Clinical Pharmacists when responding to member inquiries on the phone or on line requests for pharmacy coverage inquiries
- Ability to be a resource and subject matter expert for processing and resolving pended medical claims and perform pharmaceutical pricing calculations for reimbursement
- Ability to be a resource for rejected pharmacy or medical claims and the ability to provide details regarding Utilization Management edits and communicate the with attention to detail, patience, professionalism while handling difficult customers and situations.
- Ability to provide details for activities that require evaluation or interpretation of information related to drug administration and treatments.
- Must have the ability to interact effectively with a variety of health care professionals, including physicians, nurses, pharmacists, pharmacy staff and billing staff and members as well as Pharmacy Technicians within the department.
- Ability to identify issue and trends that are preventing deadlines and time frames to not be met timely or accurately according to the department policies and procedures.
- Responsible for knowing and interpreting pharmacy and medical benefits.
- Ability to research and gather supporting documentation related to the facts and circumstances of a pharmacy complaint, a member appeal for coverage determination or a customer grievance related to a pharmacy issue.
- Ability to present completed pharmacy research files along with recommendations for resolution to the Complaint Management Coordinator within the internal timeframes to remain in compliance with regulatory requirements for pharmacy appeals, pharmacy grievances and or pharmacy complaints.
- Assist with special projects and or assignments designated by the Pharmacy Management Team.
- Knowledge of Medical terminology and HIPAA regulations
- Knowledge of Health care coding systems such as ICD 9 CPT and HCPCS
- 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.
- Serve as primary liaison for Mail Order Pharmacy, Specialty Pharmacy, Appeals Grievances, Claims, Provider Services and other external internal areas
We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!
Learn more about our employee benefits:
https://www.phs.org/careers/employee-benefits/Pages/default.aspx
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. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.
Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.
New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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