- Determines appropriateness for medications. Communicates decision to physicians, physician`s office staff, medical management staff and/or pharmacists. Researches, resolves and documents prior authorization outcomes in pharmacy system.
- Communicates selected prior authorization criteria, pharmacy benefit coverage and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.
- Escalates requests to Pharmacist when request requires extensive clinical review or denial.
- Monitors telephone system to ensure adequate staffing to maintain client services levels.
- Assesses training needs within the team. Serves as a training resource, mentor and coach to others. Identifies and shares best practices.
- Demonstrates, advocates and reinforces a positive team environment.
- Other duties as assigned.
Other Job Requirements
Minimum two years dispensing or retail experience required, or equivalent internal training will be substituted.CPT – Certification/licensure in accordance with state requirements. In the states of Florida and Michigan, license registration with the Board of Pharmacy is required without exception.PTCB – Certification or the ability to obtain PTCB Certification within one year of hire. Employees in states which require a Pharmacy Technician certification exam may substitute state certification for the PTCB. 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. Ability to identify and trouble-shoot problematic issues.
General Job Information
GED (Required), High School (Required)
License and Certifications – Required
CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements – Pharmacy
License and Certifications – Preferred
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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