It is the policy of Computer Aid, Inc.(CAI) not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of CAI to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Employees and applicants of CAI will not be subject to harassment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. Additionally, retaliation, including intimidation, threats, or coercion, because an employee or applicant has objected to discrimination, engaged or may engage in filing a complaint, assisted in a review, investigation, or hearing or have otherwise sought to obtain their legal rights under any Federal, State, or local EEO law is prohibited.
The Pharmacy Coordinator provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan's state and federal multiple drug benefit design offerings. This position responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. By reviewing member claims history, clearly defines the medical necessity of non-formulary and prior authorization medication exception requests. Will interact with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.
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 problem solves.
Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department to include but not limited to:
Prioritization of requests for drug authorizations or denials.
Review of prior authorization criteria for drug products
Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity
Ensure call center turnaround time requirements associated with DPW/CMS regulations are adhered to
Complete other assigned duties as specified
Identify and report improper coordination of benefit billing practices through paid clams review
Participate as pharmacy representative in onsite member appeals and grievances sessions
Outreach to members to discuss adherence to medication
Serve as a resource for technical staff
Other duties as assigned or requested.
• Years of industry experience: 1 year of retail hospital experience
• Experience in pharmacy prescription claims processing/submission/payment.
• Educational requirements: High School Diploma/GED
• Experience working in a managed care medication formulary management environment
• Working knowledge of retail pharmacy and/or third party prescription procession
• 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. They must also be familiar with Medicare drug benefit design
offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation.
• Excellent computer skills such as working knowledge of Microsoft Outlook, Word
• 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
• Candidates who are fluent in Spanish are preferred, but not required
Ability to safely and successfully perform the essential job functions consistent with the ADA and other federal, state and local standards
Sedentary work that involves sitting or remaining stationary most of the time with occasional need to move around the office to attend meetings, etc.
Ability to conduct repetitive tasks on a computer, utilizing a mouse, keyboard and monitor
If you are interested in this position, please apply using the "Apply " option. If you have questions, or would like to speak with a Recruiter directly, send an email to the contact person below and note the job identification number in the subject line.