Pharmacy Coverage Determination Technician

Triple-S Management Corp.; Northern (KY); Hybrid; USD 28,000 - 38,000; Full time

Job summary

Triple-S Management Corp. in Puerto Rico seeks a Pharmacy Technician to support the Coverage Determination process within the Pharmacy Department, ensuring regulatory and program criteria are met for CMS, ASES, URAC, and state law.

You will gather clinical information, communicate with physicians, pharmacies, and enrollees, document activities, and assist in resolving cases. A technical course in pharmacy and active Puerto Rico license are required.

Qualifications

• Pharmacy Technician course with one year of experience.
• Active, unrestricted professional license to practice as a Pharmacy Technician in Puerto Rico.

Responsibilities

• Evaluate and classify coverage determination requests, distinguishing between coverage and appeals per regulations.
• Gather clinical information needed to evaluate cases and obtain missing data from physicians, pharmacies, or enrollees.
• Deliver information to the Pharmacist for timely decision using approved criteria.
• Document all case handling steps in the system.
• Prepare information letters and inform relevant parties of final decisions.
• Provide orientation to pharmacy, physician, enrollee or authorized representative about Coverage Determination and Appeals processes.
• Make calls to notify status and respond to inquiries from pharmacies and customer services.
• Engage in Outreach for adherence drugs to meet CMS Stars measures.
• Ensure clinical accuracy of plan decisions and compliance with applicable laws.

Education

Technical Course in Pharmacy

Job description

Triple-S Management Corp. in Puerto Rico seeks a Pharmacy Technician to support the Coverage Determination process within the Pharmacy Department, ensuring regulatory and program criteria are met for CMS, ASES, URAC, and state law.

You will gather clinical information, communicate with physicians, pharmacies, and enrollees, document activities, and assist in resolving cases. A technical course in pharmacy and active Puerto Rico license are required.