Managed Care Pharmacy Technician

Univera Healthcare•Albany, NY

About The Position

Under the direct supervision of a licensed pharmacist, the Managed Care Pharmacy Technician administers CDPHP member- and client-specific programs designed 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 the guidance of a licensed pharmacist and implements and monitors technical aspects of pharmacy benefits, including processing medical exception requests using approved clinical algorithms. The position also advises on pharmacy matters raised by internal and external sources and performs additional project work supporting the pharmacy department. The technician participates in a rotating on-call and holiday schedule with a utilization management pharmacist to assist members with after-hours pharmacy issues. The role requires working additional hours as needed to meet turnaround-time responsibilities and the ability to cover a late Friday shift. Work may be performed in a home office environment for extended periods for business continuity; remote work may be considered case by case. The employee must comply with CDPHP’s Corporate Compliance Policy and applicable laws, rules, regulations, and standards of conduct, and report suspected violations through the designated channels. Other duties may be assigned.

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 utilization review.
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 authorization, exception, and medical or prescription-necessity reviews.
Ability and willingness to continually develop or refine skills needed to respond to customers.
Strong customer-service orientation and ability to work effectively with internal and external customers.
Ability to work independently and apply problem-solving and analytical skills.
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; sit and/or stand while viewing a monitor and using a keyboard, mouse, and/or phone for three or more hours at a time.
Ability to hear, understand, and speak clearly while using a phone, with or without a headset.
Ability to work in a home office environment for extended periods for business continuity.

Nice To Haves

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

Responsibilities

Review medical exception requests using algorithms created by pharmacists.
Review clinical documentation submitted by physicians and pharmacists against applicable criteria to determine approval of prior authorization requests.
Assist with data entry and monitor, research, and report on member profiles related to prior authorization requests and ad hoc reports.
Provide information by telephone 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, practitioners, and pharmacists with pharmacy-benefit questions and problems.
Monitor and troubleshoot the Pharmacy Benefit Management system and other pharmacy interfaces for eligibility, claims, and formulary issues, and 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 the Corporate Compliance Policy and applicable laws and standards, and report suspected violations through designated channels.
Perform other duties as assigned.