Clinical Pharmacy Review Specialist

Presbyterian Healthcare Services

1d • $18 - $27 • Onsite

About The Position

Presbyterian is hiring a skilled Clinical Pharmacy Review Specialist to join our team. The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department. This position is responsible for providing clinical support for the Fluent Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances.

Requirements

• GED or High School diploma is required.
• Certified Pharmacy Technician-PTCB is required
• 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.
• Effective oral and written communication skills.
• Knowledge of Medical terminology and HIPAA regulations

Nice To Haves

• Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred
• Retail Pharmacy experience preferred
• Managed care customer service experience preferred
• Drug Information skills
• Experience with Medicare Part D insurance and Medicaid programs

Responsibilities

• Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocols
• Completes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasks
• Assign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.
• Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.
• 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.
• Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiries
• Effective oral and written communication skills.
• Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.
• May perform activities that require evaluation or interpretation of information related to drug administration and treatments.
• Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy Management
• Ability to meet established deadlines timely, accurately and with a sense of urgency
• Responsible for knowing and interpreting pharmacy and medical benefits.
• Knowledge of Medical terminology and HIPAA regulations
• Perform other duties as assigned.

Benefits

• medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
• Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED