Pharmacy Technician - Utilization Management

BlueCross BlueShield of South Carolina•Columbia, SC

53d•Onsite

About The Position

Position Purpose: Responsible for setting up cases for pharmacy authorization requests and performing pharmacy reviews as per established criteria. Maintains the timely, complete, and accurate processing of authorization requests by interfacing with internal and external customers and the Pharmacy Benefit Manager (PBM) to resolve issues that may arise in the provision of pharmacy services. Processes determination letters and documents decisions using indicated protocol or clinical guidelines. Participates in quality control and/or quality improvement activities.

Requirements

High School Diploma or equivalent
3 years pharmacy technician experience.
Working knowledge of pharmaceutical claims, language, drug usage and generic substitution practices.
Good judgment.
Demonstrated customer service and organizational skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Attention to detail and the ability to handle multiple demands and balance multiple priorities in a fast-paced environment.
Ability to remain in a stationary position and operate a computer.
Microsoft Office.
Registered Pharmacy Technician with the applicable state Board of Pharmacy and Certified Pharmacy Technician.

Nice To Haves

3 years-pharmacy experience in managed care setting or PBM.

Responsibilities

Receives and builds cases in the various applications for pharmacy authorization requests.
Under Pharmacist guidance and per company policies/guidelines and established criteria sets, reviews, evaluates and authorizes approval of pharmacy requests.
Requests additional information from providers including confidential medical history and prior drug therapy, in order to properly evaluate the request.
Determines appropriateness for medications.
Processes determination letters and communicates decision to providers and/or members ensuring timeliness and accuracy.
Researches, resolves and documents outcomes in pharmacy system.
Communicates selected authorization criteria, pharmacy benefit coverage, formulary alternatives and/or Pharmacy Management program policies and procedures to pharmacy providers, members and internal contacts.
Conducts research necessary to make thorough/accurate basis for each determination made.
Loads authorization into the system and ensures the clinical determination is documented accurately into the system for all levels of care.
Utilizes allocated resources to back up review determinations.
Completes all assigned work within established timeliness guidelines.
Identifies and makes referrals to appropriate staff (Pharmacist, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.).
Escalates requests to Pharmacist when request requires extensive clinical review.
Establishes and maintains effective relationships with providers, members and internal contacts.
Responds appropriately to inquiries received from providers, members and internal contacts.
Researches and resolves issues using the appropriate reference material.
Participates in quality control and/or quality improvement activities in support of the corporate and team-based objectives.
Participates in all Required Licenses and Certificates.