Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Performs QA of medical exception/prior authorization processing and submits report to supervisor for review. Identifies patterns for training needs and develops training materials for new hires.Coordinates with other internal departments as needed for resolution of system error updates that are discovered.
Performs quality assurance (QA) of medical exception overrides. Compiles report and identifies training needs and reviews with supervisor.
Develops and maintains training materials for new hires.
Provides assistance and coaching to other staff when help is needed in resolving a claim submission error. Acts as a mentor to the department.
Assists supervisor in completing special projects as necessary.
Identifies system errors with override completion and acts as point person to communicate with appropriate management for resolution.
Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria. Refers all cases not meeting clinical criteria to pharmacist clinical reviewer.
Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client. - Assists with the documentation and implementation of both written and verbal communications to physicians/prescribers and assists in the maintenance of the edits and data elements that support the edits.
Available for consultation in pharmacy related questions to resolve claims submission related to medication edits.
Regularly reviews and monitors information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data.
Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies.
Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary.
Other duties as assigned.
Other Job Requirements
Responsibilities
Must have an active pharmacy technician licensure or registration in accordance with state requirements.If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT).In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT).Minimum of 7 years of pharmacy experience without a Bachelor's degree OR 4 years of pharmacy experience with a Bachelor's degree in Science, Health, Medical or related field ORSpecialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing.Strong team orientation with respect for all members.Excellent verbal and written communications skills.People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position.Analytic skills which can translate into practical and pragmatic recommendations.In-depth knowledge of medical exception/prior authorization process and claims submission to resolve reimbursement issues. Expertise in client line of business to recognize system and process errors in order to escalate concerns in an organized, professional manner.
General Job Information
Title
Lead Initial Review Pharmacy Technician
Grade
22
Work Experience - Required
Clinical, Pharmacy
Work Experience - Preferred
Education - Required
GED, High School
Education - Preferred
Bachelors
License and Certifications - Required
CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive.
Magellan is committed to providing equal employment opportunities to employees and applicants for employment without regard to race, color, creed, religion, sex, gender identity and expression, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical or mental disability, disabled veteran or veteran of the Vietnam Era status, or any other factors protected by law.
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Please know that Magellan Health does not interview any candidate through email, nor do we issue checks to candidates to set up home offices. All of our available positions are posted on legitimate job boards and our recruitment team directly contacts candidates should there be a fit.
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