Reviews rejected pharmacy claims for appropriateness.
Becomes a pharmacy claim processing subject matter expert and triages claims issues.
Assist with resolution of rejected pharmacy claims via provider and/or pharmacy outreach.
Compiles, interprets, documents, and tracks findings from pharmacy claims monitoring data.
Becomes subject expert with Medicare Part D policies and procedures.
Reviews Part D transition claims reports.
Interacts with the pharmacy benefits manager, pharmacies, prescribers, and members to ensure appropriate and timely member access to prescription drugs.
Supports medical pharmacy prior authorizations (Part B).
Supports Medicare Part D Customer Service call center questions and issues received from members, pharmacies, and providers.
Supports compliance functions and requests, including support of the pharmacy department during CMS (Centers for Medicare and Medicare Services) audits when applicable.
Supports quality programs including STARS.
Conducts retrospective claims reviews.
Requirements
High school diploma, GED, or equivalent
Current Certified Pharmacy Technician License in good standing
1+ years Pharmacy Technician or retail pharmacy experience or the knowledge, skills, and abilities to succeed in the role
Flexible with the ability to consistently meet deadlines and adapt to a changing work environment
Strong planning, time management, and organizational skills
Team player with a positive attitude
Strong professional verbal and written communication skills
Basic PC skills, including Microsoft Excel, Word, and Outlook
Preferred 2+ years of experience in retail pharmacy
2+ years of Pharmacy Technician experience
Part D health plan or pharmacy benefit management experience
Certified Pharmacy Technician License
Benefits
Medical, Vision and Dental Plans
Tax-Advantage Savings Accounts (FSA & HSA)
Life Insurance and Disability Insurance
Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)