Clinical Pharmacy Review Specialist

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 28,000 - 47,000; Full time

Benefits offered by this job

Wellness program

Comprehensive benefits package

Job summary

Presbyterian Healthcare Services in Albuquerque, NM seeks a Clinical Pharmacy Review Specialist to support the Pharmacy Services Department. You will perform clinical data reviews for coverage determinations, prior authorizations, and appeals, and you will interact with members, providers and staff to resolve coverage questions.

Key responsibilities include screening requests, gathering information from prescribers, and assisting pharmacists with medication therapy management.

Qualifications

• GED or high school diploma is required.
• Certified Pharmacy Technician (PTCB) certification is required.
• Experience with pharmacy benefits management or prescription benefits is preferred.

Responsibilities

• Performs first level review and evaluation of prior authorization requests for appropriateness, policy deviations, coverage criteria or protocols.
• Completes documentation review and requests information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Enter and interpret submitted documentation regarding prior authorization requests into the appropriate claims processing system.
• Communicate information to members, providers, pharmacists and staff on issues related to benefit coverage and formulary criteria.
• Assist Clinical Pharmacist in review of members' medication regimens and support Medication Therapy Management.

Skills

Communication skills

Critical thinking

Clinical knowledge

Team collaboration

Education

GED or High School diploma

Certified Pharmacy Technician-PTCB

Job description

Location Address:9521 San Mateo NE Albuquerque, NM 87113-2237Compensation Pay Range:Minimum Offer $20.10 Maximum Offer $34.21 Now Hiring: Clinical Pharmacy Review SpecialistSummary:Build your Career. Make a Difference. Presbyterian is hiring a skilled Clinical Pharmacy Review Specialist to join our team. Type of Opportunity: Full time Job Exempt: No Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)Responsibilities:The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.This position is responsible for providing clinical support for the Fluent Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances.Some key responsibilities include:Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocolsCompletes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasksAssign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs.Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiriesEffective oral and written communication skills.Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.May perform activities that require evaluation or interpretation of information related to drug administration and treatments.Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy ManagementAbility to meet established deadlines timely, accurately and with a sense of urgencyResponsible for knowing and interpreting pharmacy and medical benefits.Knowledge of Medical terminology and HIPAA regulationsPerform other duties as assigned.Qualifications:GED or High School diploma is required.Certified Pharmacy Technician-PTCB is requiredExperience with pharmacy benefits management, health insurance and or prescription benefits is preferredRetail Pharmacy experience preferredManaged care customer service experience preferredDrug Information skillsExperience with Medicare Part D insurance and Medicaid programsAll benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.WellnessPresbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.Why work at Presbyterian?As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.About Presbyterian Healthcare ServicesPresbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services