Clinical Pharmacy Review Specialist

0100 PHP Administrative; New Mexico; Hybrid; USD 28.000 - 47.000; Vollzeit

Zusammenfassung

Presbyterian Healthcare Services is seeking a Clinical Pharmacy Review Specialist for a remote-based role in New Mexico. You will support clinical case reviews, prepare data for coverage determinations, prior authorizations, and member reimbursements.

The role requires PTCB certification, GED or higher, and PBM/Medicare Part D experience. Strong communication and HIPAA knowledge are essential, with duties spanning documentation, claims review, and MTM assistance.

Qualifikationen

• GED or High School diploma required.
• Certified Pharmacy Technician (PTCB) required.
• Experience with pharmacy benefits management, health insurance or prescription benefits preferred.

Aufgaben

• Perform first-level review and evaluation of prior authorization requests.
• Prepare and research clinical data for coverage determinations and appeals.
• Enter and interpret documentation in the claims processing system.
• Communicate benefit coverage and formulary information to members and providers.
• Assist Pharmacist in reviewing member medication regimens and MTM.
• Meet deadlines with accuracy and urgency.

Kenntnisse

Clinical pharmacy

Prior authorization

Medicare Part D

HIPAA compliance

Member communication

Pharmacy benefits

Ausbildung

GED or High School diploma

PTCB certification

Tools

Claims processing system

Jobbeschreibung

Location Address: Remote Office Santa Fe, NM 87501

Compensation Pay Range: Minimum Offer $20.10 Maximum Offer $34.21

Now Hiring: Clinical Pharmacy Review Specialist

Summary: 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: Remote Workers New Mexico

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 protocols Completes 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 tasks Assign, 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 inquiries Effective 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 Management Ability to meet established deadlines timely, accurately and with a sense of urgency Responsible for knowing and interpreting pharmacy and medical benefits. Knowledge of Medical terminology and HIPAA regulations Perform other duties as assigned.

Qualifications

GED or High School diploma is required. Certified Pharmacy Technician-PTCB is required Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred Retail Pharmacy experience preferred Managed care customer service experience preferred Drug Information skills Experience with Medicare Part D insurance and Medicaid programs All 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. Wellness Presbyterian'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.

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

Here, we’re committed to a different way to make a difference. Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, nurses, employees, board members, and volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than one in three New Mexicans. We are part of New Mexico's history and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.