Pharmacy Technician - UM

Inland Empire Health Plan•, CA

8d•$27 - $36•Hybrid

About The Position

Under the direction of the Supervisor, Pharmacy Utilization Management (RxUM), the Pharmacy Technician - Utilization Management (RxUM) is responsible for the technical/clinical review of the utilization management authorization request with a medication component. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

One (1) or more years of experience as a pharmacy technician in a pharmacy required
High School Diploma or GED required
Possession of an active, unrestricted, and unencumbered Pharmacy Technician license issued by the California State Board of Pharmacy required
Knowledge in pharmaceutical terminology is required
Excellent organizational, written, and verbal communication required
Typing speed of 40 corrected words per minute (CWPM) required.
Microsoft Office (Microsoft Excel skills preferred)
Good interpersonal skills
Excellent critical thinking skills

Nice To Haves

Experience in a pharmacy benefit management setting preferred

Responsibilities

Input, review and decision Medicare Part B and Medi-Cal requests for J codes, S code, Q codes, B codes and other medical benefits drugs/supplies.
Review Requests based on UM logic and criteria including but not limited to LCD, NCD, UM manual, MCG, MDX and other establish criteria when applicable.
Technical/Clinical review of authorizations (drug and utilization management) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation.
Decision prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
Ensure all company’s goals (including, but not limited to the 6 Strategic Priorities: Member Experience, Network, Team Member, Operational Excellence, Technology, and Financial Stewardship).
Communicate with providers (doctor and pharmacy) on issues related to the IEHP RxUM policies and procedures.
Interface with IEHP’s pharmacy benefit management (PBM) company, when necessary, in regard to adjudication and medication processing issues.
Assist in expedited review of discharge related orders or requests and coordination with specialty pharmacy providers (disease therapy management program), and internally with Utilization Management, Behavioral Health, or Care Management departments.
Assist Clinical Pharmacist in review of Member’s medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments.
Actively participate in internal quality improvement process enhancements, LEAN projects, and managing for daily improvement (MDI).
Participate in various pharmacy projects to meet the standards of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Projects included, but not limited to, pharmacy utilization management review, provider and pharmacy outreach, formulary alternative conversion and discharge medication transition.
Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues.
Any other duties as required to ensure Health Plan operations are successful.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.