The Pharmacy Technician works closely with Western Health Advantage’s (WHA) Chief Pharmacy Officer, Pharmacy Manager, Medical Directors, Clinical Pharmacists and Pharmacy Coordinator to ensure pharmacy utilization management review functions are carried out effectively at the health plan level. The Pharmacy Technician may work with several internal departments to assist with pharmacy related benefit interpretation, provide pharmacy related assistance, and provide problem solving on appeal and grievance cases as needed. This position also evaluates and performs utilization review of prescription medication requests under the protocols and criteria developed by the Chief Pharmacy Officer, Pharmacy Manager and Clinical Pharmacists. This position assists in creating as well as updating and maintaining current written procedures for the team.
• Perform authorization review of prescription medication requests utilizing established protocols and criteria developed by the Pharmacy leaders and Clinical Pharmacists, transferring all clinical questions and judgements falling outside the standardized criteria to the Clinical Pharmacists for review.
• Coordinate with Pharmacy Coordinator and other internal departments to ensure authorization decisions and notifications to members and providers are completed in compliance with regulatory requirements.
• Assist Member Service Representatives and Individual Plan Administrators/Medical Group staff with interpretation of pharmacy benefits and criteria.
• Research, review, and when indicated, prepare cases for Pharmacy leaders, Pharmacist, and/or Chief Medical Officer review, and ensure timely and appropriate follow-up by creating and sending authorization/approval or denial letters.
• Assist in maintaining the WHA Formulary Drug List and Pharmacy Prior Authorization (PA) Criteria per the Pharmacy and Therapeutics (P&T) Committee decisions.
• Assist Pharmacy leaders with accreditation audits by the Department of Managed Health Care (DMHC) regulatory and National Committee of Quality Assurance (NCQA).
• Assist Pharmacy leaders with pharmacy/PBM related audit tasks.
• Ensure timely creation and processing of denial letters for cases denied by Clinical Pharmacists.
• Maintain current knowledge of medications and drug classifications.
• Responsible for helping support administrative functions such as notifications to providers, members and supporting return mail process.
• Support development of Pharmacy policy procedures, training material, and desk level procedures.
• Work with the Pharmacy leaders to ensure there is appropriate coverage during holidays and Friday night to ensure all cases are completed to comply with regulatory requirements.
• Experienced Pharmacy Technicians are responsible for mentoring and/or training new and less experienced Pharmacy Technicians and Pharmacy Coordinators and serve as resources in answering questions.
• Support, review, and research pharmacy related cases for Appeals and Grievances.
• Responsible for helping support administrative functions such as notifications to providers and members, and processing returned mail.
• Perform other duties and special projects as assigned.
• High School Diploma.
• Three years of experience as Pharmacy Technician.
• Two years of experience working in a utilization/managed care environment.
• One year of experience working in a customer service or call center environment is highly desired.
• Must have valid California Pharmacy Technician License in good standing and must be maintained throughout employment.
• Experience with writing in business correspondence style.
• Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc.
• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.
$21.00 - $26.00 Hourly (EOE)
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
*WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’...Integral Senior Living, proudly part of the Discovery Senior Living family of operating companies, manages care and lifestyle-focused senior living communities. Our company, which was built on our Culture Keepers, employees thousands of vital Team Members and is committed...
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