Highmark Health
Overview
Company: Highmark Inc. Job Description Summary: This role provides frontline staff guidance and ensures effective and efficient delivery of Pharmacy call center services. It acts as the first line reviewer to monitor and ensure adherence to the health plan’s state and federal drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medications, and drug claim edits/prior authorizations. By reviewing member claims history, the role clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. The incumbent interacts with pharmacy network providers to evaluate, educate, and assist in addressing denied point-of-sale prescription claim transitions and coordination of benefits practices and procedures. Responsibilities
Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful, and timely manner.
Interact with staff to implement processes and solve problems.
Respond to drug benefit design inquiries or exception requests and evaluate/direct daily workflow within the department.
Prioritize requests for drug authorizations or denials.
Review prior authorization criteria for drug products.
Recommend staffing adjustments necessary to maintain a high level of efficiency/productivity.
Ensure adherence to call center turnaround time requirements associated with DPW/CMS regulations.
Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization, or claim override.
Search member claim history profile and recommend formulary alternatives wherever feasible.
Contact physician network providers to obtain necessary and/or additional information when necessary.
Consult with staff clinical pharmacist for guidance and assistance as necessary.
Document all authorizations and denials completely, accurately, and in accordance with timelines as defined by state and federal regulations to ensure appropriate notification issuance to prescribing physician and impacted member.
Populate all authorization and denial information fields within the OnBase information system.
Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
Complete other assigned duties as specified.
Identify and report improper coordination of benefit billing practices through paid claims review.
Participate as pharmacy representative in onsite member appeals and grievances sessions.
Serve as a resource for technical staff.
Other duties as assigned or requested.
Qualifications
Minimum High school diploma or GED
Experience in pharmacy prescription claims processing/submission/payment
Preferred Associate degree
Pharmacy technician certification
Experience working in a managed care medication formulary management environment
Working knowledge of retail pharmacy and/or third party prescription processing
Strong background and understanding of medications and formulary terminology
Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states, and with Medicare drug benefit design offerings that may differ by state, while understanding applicable federal rules/regulations that remain consistent nationwide
Skills Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
Excellent interpersonal, communication and attentive listening skills
Strong organizational skills, detail oriented
Demonstrated excellence in communication skills
Demonstrated ability to work well with others
Demonstrated ability to work in a fast-paced, multi-task environment
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No WORK ENVIRONMENT
Is Travel Required? No Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to protected information, and all employees must comply with HIPAA and data security guidelines as described in company policies. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations. Req ID: J267189
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Company: Highmark Inc. Job Description Summary: This role provides frontline staff guidance and ensures effective and efficient delivery of Pharmacy call center services. It acts as the first line reviewer to monitor and ensure adherence to the health plan’s state and federal drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medications, and drug claim edits/prior authorizations. By reviewing member claims history, the role clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. The incumbent interacts with pharmacy network providers to evaluate, educate, and assist in addressing denied point-of-sale prescription claim transitions and coordination of benefits practices and procedures. Responsibilities
Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful, and timely manner.
Interact with staff to implement processes and solve problems.
Respond to drug benefit design inquiries or exception requests and evaluate/direct daily workflow within the department.
Prioritize requests for drug authorizations or denials.
Review prior authorization criteria for drug products.
Recommend staffing adjustments necessary to maintain a high level of efficiency/productivity.
Ensure adherence to call center turnaround time requirements associated with DPW/CMS regulations.
Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization, or claim override.
Search member claim history profile and recommend formulary alternatives wherever feasible.
Contact physician network providers to obtain necessary and/or additional information when necessary.
Consult with staff clinical pharmacist for guidance and assistance as necessary.
Document all authorizations and denials completely, accurately, and in accordance with timelines as defined by state and federal regulations to ensure appropriate notification issuance to prescribing physician and impacted member.
Populate all authorization and denial information fields within the OnBase information system.
Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
Complete other assigned duties as specified.
Identify and report improper coordination of benefit billing practices through paid claims review.
Participate as pharmacy representative in onsite member appeals and grievances sessions.
Serve as a resource for technical staff.
Other duties as assigned or requested.
Qualifications
Minimum High school diploma or GED
Experience in pharmacy prescription claims processing/submission/payment
Preferred Associate degree
Pharmacy technician certification
Experience working in a managed care medication formulary management environment
Working knowledge of retail pharmacy and/or third party prescription processing
Strong background and understanding of medications and formulary terminology
Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states, and with Medicare drug benefit design offerings that may differ by state, while understanding applicable federal rules/regulations that remain consistent nationwide
Skills Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
Excellent interpersonal, communication and attentive listening skills
Strong organizational skills, detail oriented
Demonstrated excellence in communication skills
Demonstrated ability to work well with others
Demonstrated ability to work in a fast-paced, multi-task environment
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees? No WORK ENVIRONMENT
Is Travel Required? No Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to protected information, and all employees must comply with HIPAA and data security guidelines as described in company policies. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations. Req ID: J267189
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