Impactful Clinical Utilization Review Pharmacy Technician

Prime Therapeutics LLC; Albuquerque (NM); On-site; USD 32,000 - 51,000; Full time

Job summary

Prime Therapeutics LLC in Albuquerque, NM seeks an Initial Review Pharmacy Technician to support utilization management for health plans. You will review requests for therapeutic appropriateness, gather clinical information, and communicate with physicians, patients and pharmacies to determine medication reimbursement.

Requirements include an Associate's degree and 2+ years of pharmacy experience; state licensure varies. Oncology or high-volume call center exposure is a plus.

Qualifications

• Associate's degree or equivalent combination of education and/or work experience in similar field; HS diploma or GED is required
• 2+ years of Pharmacy Experience
• CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
• Minimum of 2 years of pharmacy experience without a Bachelors degree OR 2 years of pharmacy experience with a Bachelor’s degree
• Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting
• Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment
• Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing

Responsibilities

• Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria.
• Refers all cases not meeting clinical criteria to pharmacist clinical reviewer.
• Adheres to company policies and procedures to uphold clinical integrity of pharmaceutical solutions.
• Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization.
• Maintains communications with physicians/prescribers and assists in maintenance of edits and data elements that support the edits.
• Provides consultation in pharmacy related questions to resolve claims submission issues.
• Reviews and monitors information on pended claims identified as outliers.
• Supports Intake call volume and order entry if necessary.
• Determines eligibility for medication reimbursement based upon established clinical criteria and enters approvals or denials.
• Documents communications with physicians, their staff, cardholders, and pharmacies.
• Escalates medical exception requests to nurse, pharmacist or physician when needed.
• Other duties as assigned.

Skills

Pharmacy experience

Utilization management

Clinical communication

Data gathering

Education

Associate's degree or equivalent

Bachelor's degree in Science/Health/Medical

Tools

Microsoft Office

Job description

Prime Therapeutics LLC in Albuquerque, NM seeks an Initial Review Pharmacy Technician to support utilization management for health plans. You will review requests for therapeutic appropriateness, gather clinical information, and communicate with physicians, patients and pharmacies to determine medication reimbursement.

Requirements include an Associate's degree and 2+ years of pharmacy experience; state licensure varies. Oncology or high-volume call center exposure is a plus.