Managed Care Pharmacy Technician

Excellus BCBS•Albany, NY

About The Position

Under the direct supervision of a licensed pharmacist, the Managed Care Pharmacy Technician administers member- and client-specific programs intended to optimize pharmacy benefits and the prescription process. The role handles live calls with members, physicians, and pharmacists, providing information about pharmacy benefits, formulary coverage, and CDPHP initiatives. It supports prior authorization work under pharmacist guidance and implements and monitors technical aspects of pharmacy benefits, including processing medical exception requests using approved clinical algorithms. The technician also advises on pharmacy matters raised by internal and external sources and contributes to ad hoc projects supporting the pharmacy department. The position participates in a rotating on-call and holiday schedule with a utilization management pharmacist to assist Plan members with after-hours pharmacy issues. The technician may work additional hours to meet turnaround-time responsibilities and must be able to cover a late shift on Fridays. The role includes computer-based work in a workstation or home-office environment for extended periods.

Requirements

High school diploma and at least two years of experience in a health-related field.
Basic understanding and interpretation of medical terminology and diagnosis codes.
Basic understanding of drug classes and therapeutic interchange as described in drug policies.
Clear understanding of prescription and medical benefits as they apply to the utilization review process.
Proficient experience with the Microsoft Office suite.
Strong verbal and written communication skills.
Professionalism, a strong work ethic, and the ability to maintain a positive attitude when working with internal and external customers.
Conscientiousness, efficiency, and accuracy in processing prior authorizations, exceptions, and medical or prescription-necessity reviews.
Ability to continually develop or refine skills needed to respond to customers.
Strong customer-service orientation and ability to interface effectively with internal and external customers.
Ability to work independently and apply problem-solving and analytical abilities.
Ability to cover rotating on-call responsibilities and a late shift on Fridays.
Ability to work additional hours as needed to meet turnaround-time responsibilities.
Ability to work for prolonged periods seated at a workstation using a computer.
Ability to sit and/or stand at a workstation and use a monitor, keyboard, mouse, and/or phone for three or more hours at a time.
Ability to work in a home-office environment for extended periods for business continuity.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.

Nice To Haves

Associate degree.
Pharmacy Technician certification (CPhT), LPN, or Medical Assistant/Technologist background.

Responsibilities

Review medical exception requests using algorithms created by pharmacists.
Compare clinical documentation submitted by physicians and pharmacists with applicable criteria to determine whether prior authorization requests meet requirements.
Assist with data entry and monitor and research member profiles for prior authorization requests and ad hoc reports.
Provide telephone information to physicians and pharmacists about initiatives involving member prescriptions.
Provide real-time authorization certification for prescription medication requests involving vacation supplies, duplication-of-therapy overrides, medication synchronization, and package-size issues.
Implement formulary utilization management tools, including prior authorization, quantity limits, step therapy, dose optimization, and age or gender restrictions.
Work with internal and external customers to identify, analyze, and resolve difficult situations, including Pharmacy benefit system issues.
Research and resolve issues related to mail-order service, specialty pharmacy, and pharmacy claims processed in the Plan’s Facets system.
Provide backup coverage for the Pharmacy Benefits Team phone queue as needed, assisting internal departments, external practitioners, and pharmacists with pharmacy-benefit questions or problems.
Monitor and troubleshoot the Pharmacy Benefit Management system and other pharmacy interfaces for eligibility, claims, and formulary issues; conduct interface testing as needed.
Monitor production and quality improvement, and work with management and staff to support Pharmacy department quality standards.
Establish productivity and quality standards in conjunction with the supervisor.
Attend staff meetings and in-service programs as requested.
Perform rotating on-call responsibilities, including holidays and evenings.
Work additional hours as needed to meet turnaround-time responsibilities.
Comply with CDPHP’s Corporate Compliance Policy and applicable laws, rules, regulations, and standards of conduct, and report suspected violations through the designated channels.
Perform other duties as assigned.