Pharmacy Services (Digital Support) Technician

Cambia Health Solutions • Medford, OR

3d • Remote

About The Position

Cambia's dedicated Pharmacy Services Technicians are living our mission to make health care easier and lives better. As a member of the Pharmacy Operations team, our Pharmacy Services Technician is a corporate-wide technical support resource for pharmacy benefit, reimbursement, and other drug use issues which do not require clinical judgment. This function assists the Clinical Pharmacy Consultants and Pharmacy Services staff with formulary-related operations and other operational processes which require knowledge and experience with pharmaceuticals, all-in service of creating a person-focused health care experience.

Requirements

• High school diploma or related certificate and 5 years of experience as a pharmacy services technician in a retail, hospital, or other licensed pharmacy setting, or equivalent combination of education and experience
• Pharmacy Technician Certificate may substitute for 2 years of experience (reducing requirement to 3 years)
• Knowledge of medical terminology, health care coding systems such as ICD-10, CPT and HCPCS, and HIPAA regulations
• Knowledge of pharmaceutical products, including orals, injectables, infusion products, and chemotherapy
• Knowledge of general office practices and procedures, and demonstrated knowledge of grammar and techniques of business practice
• Ability to interact effectively with a variety of health care professionals, including physicians, nurses, pharmacists, and billing staff both internally and externally, while demonstrating maturity, tact, diplomacy, and persuasiveness
• Demonstrated ability to perform pharmaceutical pricing calculations and ability to type 30 words per minute, 60 wpm preferred
• Demonstrated ability to operate a variety of standard business machines including calculators, copiers, and faxes, and basic computer program skills (Word, Excel, etc.)
• Ability to organize, plan, and prioritize daily workflow and projects within time constraints
• Advanced knowledge of medical terminology and pharmaceutical products including orals, injectables, infusion products, and chemotherapy, with excellent verbal and written communication skills to interpret and convey information with tact, diplomacy, patience, and professionalism
• Proven ability to interpret policies and procedures, make decisions, and communicate complex topics effectively

Nice To Haves

• Bachelor's degree is preferred
• experience with health insurance and/or prescription benefits preferred
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings

Responsibilities

• Performs all duties as described unless clinical judgment is required, in which case the Pharmacy Services Technician will seek assistance from appropriate medical personnel who are available for support during normal business hours
• Responds to non-clinical pharmacy issues from providers, pharmacy services staff, case managers, preauthorization nurses, ENCC personnel, government programs personnel, and customer service, including formulary drug coverage, appeal and reconsideration claim status, and pricing for drug claims
• Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals
• Prepares reconsideration requests for Clinical Pharmacy Consultant review by obtaining and organizing appropriate documentation, including but not limited to medical chart notes/reports and medication profiles, and communicates information and determinations to providers and members as necessary (orally and by written documentation)
• Obtains and organizes drug utilization data, including patient specific and population-based data, in a manner which facilitates clinical review and decisions by Clinical Pharmacist Consultants, including sorting drugs into appropriate therapeutic and generic categories
• Assists with auditing and investigations of medication-related claims, cases, and providers to identify misuse of medications, misuse of resources, substance abuse, and erroneous and fraudulent billing practices, and investigates and organizes workflow for claims referred to Pharmacy Services for review and allowable determination (misc. J codes, providers on review, reconsiderations)
• Supports wellness and disease state management programs for Pharmacy Service and corporately which contribute to NCQA accreditation and ongoing quality improvement, and contributes to the corporation's quality initiatives through process improvement teams and by encouraging team and individual contributions toward quality improvement efforts
• Completes daily complex operational processes, including tracking, processing, and obtaining appropriate documentation for pharmacy medical exception requests, prior authorization requests, reconsiderations, and appeals, while navigating complicated outreaches and incoming calls with providers and members as necessary
• Responds to non-clinical complex pharmacy issues from providers, pharmacy services staff, case managers, preauthorization nurses, ENCC personnel, government programs personnel, and customer service, including formulary drug coverage, appeal and reconsideration claim status, pricing for drug claims, and coordinates peer to peer requests, consultations with clinical staff, and phone support
• May mentor and/or train pharmacy technicians on systems, policies, and procedures as needed

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

What This Job Offers

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