Job Description
Description
POSITION SUMMARY
To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship. Apply proper authorization requirements and pharmacy benefits for all QHP, Non-QHP, ASO and Medicare membership in accordance with all State Statutes, Federal guidelines, and NCQA Standards where applicable. Prepare all authorization requests requiring clinical, coverage and/or organizational determinations for the clinical reviewer; which includes, all Formulary Exception and Prior Authorization requests for both the pharmacy and medical benefit, as applicable. Process administrative authorizations by applying applicable benefits based on Contracts, State Statutes and Federal Regulations. Identify opportunities or deficiencies contributing to gaps in patient care, assisting with transition of care, assistance with disease management, or any member who may need to be followed by case management. Educate members and physicians on the prior authorization process and benefit application. Actively participate in the Pharmacy & Therapeutics (P&T) Committee and the Pharmacy Logistics Utilization Management (PLUM) Meeting.
PRIMARY ACCOUNTABILITIES
• Maintains a safe environment for both customers and team members
• Apply proper authorization requirements to all prior authorization requests
• Authorize services when all prior authorization criteria have been documented as met, as approved by the P&T Committee.
• Prepare requests requiring clinical review by a pharmacist and/or physician, which includes interpretation of all submitted medical records, lab results, office notes and provider supporting statement that are sent in support the request.
• Audit Pharmacy benefit adjudication system performance for speed and accuracy. Report any identified deficiencies.
• Participates in development of Pharmacy benefit design and local market analysis.
• Maintains appropriate communication with HFHP Management Staff.
• Collaborates with case management, outpatient and inpatient prior auth departments regarding pharmaceutical questions and referrals.
• Prepares documents and other pharmacy resource material that is used for discussion during the P&T or PLUM.
• Fully participates in development of Pharmacy benefit design and local market analysis.
• Fully participate in annual plan building with PBM.
• Continuous training on all systems and applications.
Qualifications
QUALIFICATIONS REQUIRED
• National Pharmacy Technician Certification, or Pharmacy Technician Registration with the State of Florida preferred.
• Current FL Pharmacy Technician licensure with at least 3 years of Pharmacy Technician experience required, (OR)
• A Bachelor’s Degree with at least 3 years of Managed Care, or Pharmacy Benefit Specialist experience required
• Understands all the functions of a pharmacy benefit management company.
• Able to configure pharmacy benefit software and assume all functions performed by a full-service PBM company.
• Able to make operational, member service, and financial decisions in the best interest of HFHP with oversight and training.
• Ability to review and analyze clinical data with assistance and oversight.
• Knowledge of medical terminology required.
• Prior managed care experience or pharmacy experience required.
• Ability to review medical documentation and assist in making coverage determinations due to medical necessity.
• Ability to analyze data about medication ordering patterns.
Job :
Health First Health Plans (Health Insurance)Organization :
HF Administrative Plan IncPrimary Location :
United States- Florida - Brevard County- RockledgeSchedule :
Full-timeShift Times :
8:00 am - 4:30 pmJob Level :
Associate
POSITION SUMMARY
To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship. Apply proper authorization requirements and pharmacy benefits for all QHP, Non-QHP, ASO and Medicare membership in accordance with all State Statutes, Federal guidelines, and NCQA Standards where applicable. Prepare all authorization requests requiring clinical, coverage and/or organizational determinations for the clinical reviewer; which includes, all Formulary Exception and Prior Authorization requests for both the pharmacy and medical benefit, as applicable. Process administrative authorizations by applying applicable benefits based on Contracts, State Statutes and Federal Regulations. Identify opportunities or deficiencies contributing to gaps in patient care, assisting with transition of care, assistance with disease management, or any member who may need to be followed by case management. Educate members and physicians on the prior authorization process and benefit application. Actively participate in the Pharmacy & Therapeutics (P&T) Committee and the Pharmacy Logistics Utilization Management (PLUM) Meeting.
PRIMARY ACCOUNTABILITIES
• Maintains a safe environment for both customers and team members
• Apply proper authorization requirements to all prior authorization requests
• Authorize services when all prior authorization criteria have been documented as met, as approved by the P&T Committee.
• Prepare requests requiring clinical review by a pharmacist and/or physician, which includes interpretation of all submitted medical records, lab results, office notes and provider supporting statement that are sent in support the request.
• Audit Pharmacy benefit adjudication system performance for speed and accuracy. Report any identified deficiencies.
• Participates in development of Pharmacy benefit design and local market analysis.
• Maintains appropriate communication with HFHP Management Staff.
• Collaborates with case management, outpatient and inpatient prior auth departments regarding pharmaceutical questions and referrals.
• Prepares documents and other pharmacy resource material that is used for discussion during the P&T or PLUM.
• Fully participates in development of Pharmacy benefit design and local market analysis.
• Fully participate in annual plan building with PBM.
• Continuous training on all systems and applications.
Qualifications
QUALIFICATIONS REQUIRED
• National Pharmacy Technician Certification, or Pharmacy Technician Registration with the State of Florida preferred.
• Current FL Pharmacy Technician licensure with at least 3 years of Pharmacy Technician experience required, (OR)
• A Bachelor’s Degree with at least 3 years of Managed Care, or Pharmacy Benefit Specialist experience required
• Understands all the functions of a pharmacy benefit management company.
• Able to configure pharmacy benefit software and assume all functions performed by a full-service PBM company.
• Able to make operational, member service, and financial decisions in the best interest of HFHP with oversight and training.
• Ability to review and analyze clinical data with assistance and oversight.
• Knowledge of medical terminology required.
• Prior managed care experience or pharmacy experience required.
• Ability to review medical documentation and assist in making coverage determinations due to medical necessity.
• Ability to analyze data about medication ordering patterns.
Job :
Health First Health Plans (Health Insurance)Organization :
HF Administrative Plan IncPrimary Location :
United States- Florida - Brevard County- RockledgeSchedule :
Full-timeShift Times :
8:00 am - 4:30 pmJob Level :
Associate
💡 Quick Summary
Seeking a career-building opportunity? The Pharmacy Benefit Specialist - Pharmacy position is now open for candidates interested in the Lab Technician / Pharmacist Jobs sector. This role in Rockledge offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Lab Technician / Pharmacist Jobs is a plus.
