Part-Time Pharmacy Technician: Prior Authorization & Benefits

The Health Plan (THP); Wheeling (WV); On-site; USD 33,000 - 45,000; Full time

Job summary

The Health Plan in Wheeling, WV is seeking a Pharmacy Technician to answer member, pharmacy, and provider questions and to help review drug coverage requests. You will collaborate with pharmacists to determine coverage based on benefit design and clinical criteria, handling prior authorizations and coordinating with providers.

Responsibilities include processing claims issues, documenting outcomes, and assisting customers while ensuring compliance with plan policies and procedures.

Qualifications

• High School diploma or equivalent required.
• National Pharmacy Technician Certification required.
• Minimum typing speed of 35 words per minute.
• Working knowledge of claims processing and pharmacy computer systems; Excel proficiency.
• Knowledge of generic and trade drug names.
• Ability to follow established policies and procedures.
• Strong written and spoken communication skills.
• Excellent organizational, time management and multi-tasking abilities.
• Detail oriented with strong analytical and problem-solving skills.
• Able to work independently and in a team; provide excellent customer service.

Responsibilities

• Completes medication coverage requests through prior authorization criteria and escalates when clinical review is required.
• Contacts providers to obtain necessary information for coverage requests.
• Attaches relevant policies to case documents prior to clinical review.
• Documents policy information for clinical review sessions.
• Resolves and documents coverage outcomes in PBM system and notifies physicians/members.
• Researches and resolves inquiries and grievances; documents outcomes in relevant systems.
• Verifies member plan eligibility and benefits verbally.
• Updates, modifies and extracts member information using PBM and medical review systems.
• Informs members/providers about formulary and network details.
• Assists pharmacies with processing prescription claims and troubleshooting per contract guidelines.
• Consults with clinical pharmacists for guidance as needed.
• Gathers documentation for medication reconciliation and yearly reviews; refers to Care Management Pharmacist.
• Identifies peer-to-peer requests and routes to Clinical Pharmacist or Medical Director for review.
• Interacts with staff, customer service and supervisors to ensure best practices.
• Follows all policy/procedure lines of business; meets internal KPIs.
• Explains Appeal/Grievance process to members and providers; forwards requests as per department policies.
• Assists Appeals Coordinator and Compliance with grievances as needed.
• Handles after-hours calls regarding pharmacy issues.
• Reports changes in licensure status to supervisor.

Skills

Excellent communication

Typing speed 35 wpm

Teamwork

Analytical thinking

Customer service

Organizational skills

Problem solving

Attention to detail

Ability to work independently

Following procedures

Working knowledge of claims processing

Pharmacy terminology knowledge

Education

High School diploma or equivalent

National Pharmacy Technician Certification

Health-related degree (desired)

1 year pharmacy setting experience

Tools

Microsoft Excel

Pharmacy computer systems

Phone system

Job description

The Health Plan in Wheeling, WV is seeking a Pharmacy Technician to answer member, pharmacy, and provider questions and to help review drug coverage requests. You will collaborate with pharmacists to determine coverage based on benefit design and clinical criteria, handling prior authorizations and coordinating with providers.

Responsibilities include processing claims issues, documenting outcomes, and assisting customers while ensuring compliance with plan policies and procedures.