Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing specialty injectable utilization management programs on behalf of health plan/payor customers. Often the first point of contact that a providers office has when initiating an authorization for injectable or infused product. Requires communication and teamwork across all departments (Account Management, Specialty Pharmacy, IT, Project Management, Quality), as well as health plan/payor departments (medical management, pharmacy management) and an in-depth understanding of all specialty injectable therapeutic classes, products, trends, current management techniques and industry guidelines.
Provides outstanding customer service while also achieving department performance metrics.
In addition to the Utilization Management duties, this role serves as the UM/CS functional expert.
Uses expertise to aid others in issues which cannot be resolved or the amount of time involved in resolving the issue is anticipated to be excessive.
Provides assistance and coaching to other clinical pharmacy technicians when they require help in servicing a call.
Identifies individual clinical pharmacy technician training needs and work to address these needs. Act as a mentor to other clinical pharmacy technicians.
Assists in the monitoring and auditing staff calls to ensure accuracy and professionalism.
Assists the Supervisor in completing special projects as deemed necessary.
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).
Specialty or retail pharmacy industry experience, previous reimbursement experience, and/or working in a health plan/health care setting.
In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques, medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-9, CMS 1500, etc.).
Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.
Excellent written and verbal communication skills.
Ability to follow clinical criteria and instructions to approve prior authorization requests.
Minimum of 2 years dispensing or retail experience required, or equivalent internal training will be substituted. 5+ years of experience in comparable role in a high-volume, multi-functional call center environment.
Ability to identify and trouble-shoot problematic issues.
For positions supporting Medicare Part B, requires 2+ years of experience in Medicare Part B.
General Job Information
Title
Lead Utilization Management Specialist-2
Grade
19
Work Experience - Required
Customer Service, Pharmacy
Work Experience - Preferred
Education - Required
GED, High School
Education - Preferred
Associates - Pharmacy
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.
