Pharmacy Senior Technician

MCS Puerto Rico; San Juan (PR); Presencial; USD 35.000 - 48.000; Jornada completa

Descripción de la vacante

MCS Puerto Rico is seeking a skilled Pharmacy Technician to perform comprehensive reviews of cases in PBM systems, ensuring accurate processing within Coverage and Organizational Determinations. The role focuses on compliance, data integrity, and timely handling of pre-authorization and appeal cases.

The candidate should hold an Associate Degree in Pharmacy Technician with a valid license, 2+ years in a Pharmacy Clinical unit, and knowledge of ICD-10 and CPT procedures.

Formación

• Associate degree in Pharmacy Technician required.
• 2+ years of experience in a Pharmacy Clinical unit preferred.
• Valid Pharmacy Technician License and Registration required.
• Knowledge of ICD-10 criteria and CPT procedures preferred.

Responsabilidades

• Reviews cases flagged in processing systems for errors or incomplete information related to coverage and organizational determinations.
• Evaluates case classification (coverage/organizational determination or appeal) and prioritization (standard or expedited).
• Ensures data completeness and accuracy of fields completed by pharmacy technicians and case evaluations.
• Generates reports identifying misclassified Part D/pharmacy benefit cases and invalid formulary exceptions for the year.

Conocimientos

Regulatory compliance

Quality review

Report generation

Process improvement

Attention to detail

Bilingual communication

Educación

Associate Degree in Pharmacy Technician

Herramientas

Win Net

ICD-10 knowledge

CPT procedures knowledge

Descripción del empleo

GENERAL DESCRIPTION

Conducts comprehensive reviews of all cases in the quality review tray within the Pharmacy Benefit Management (PBM) systems, including the request processing and pharmacy claims adjudication tools. Ensures accurate case handling in accordance with Coverage and Organizational Determinations processes and maintains compliance with all applicable regulatory requirements across the company’s business lines.

Regular
Non-Exempt

GENERAL DESCRIPTION

Conducts comprehensive reviews of all cases in the quality review tray within the Pharmacy Benefit Management (PBM) systems, including the request processing and pharmacy claims adjudication tools. Ensures accurate case handling in accordance with Coverage and Organizational Determinations processes and maintains compliance with all applicable regulatory requirements across the company’s business lines.

ESSENTIAL FUNCTIONS

• Reviews cases flagged in processing systems for errors or incomplete information related to coverage and organizational determinations.


• Identifies and resolves missed cases within the PBM adjudication system to ensure accurate processing.


• Evaluates each case for proper classification (coverage/organizational determination or appeal), prioritization (standard or expedited), decision outcomes, and denial letter accuracy.


• Validates completeness and correctness of all fields completed by pharmacy technicians and the corresponding case evaluations.


• Generates reports identifying Part D/pharmacy benefit cases requiring pre-authorization that were incorrectly classified, and flags formulary exceptions invalid for the respective calendar year.


• Ensures uninterrupted mailing of letters by verifying that the data sent through Win Net matches the system records for each case, including date and time of mailing.


• Facilitates reassignment of cases received via fax, web, or electronic prior authorization (ePA) among Pharmacy Technicians.


• Supports supervisors and group leaders by providing retraining to Pharmacy Technicians on operational, regulatory, or management-directed updates.


• Monitors audit-related reports generated within the system and takes necessary actions when required.


• Contributes to the review and updating of operational guidelines, policies, and procedures.


• Assists in the evaluation and review of applications received for both business lines when needed.


• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.


• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS

Education and Experience: Associate Degree in Pharmacy Technician. At least two (2) years of experience working in a Pharmacy Clinical unit within the Healthcare Industry is preferred, with demonstrated expertise in coverage and organizational determinations, appeals processing, regulatory compliance, quality review, report generation, and process improvement.

Certifications / Licenses: A valid Pharmacy Technician License and Registration is required.

Other: Knowledge of ICD-10 clinical criteria and codes and CPT procedures is preferred. Knowledge of Part D pharmacy benefits and formulary exception processes is highly desirable.

Languages:

Spanish – Intermediate (comprehensive, writing, and verbal)
English – Intermediate (comprehensive, writing, and verbal)

“We are an Equal Employment Opportunity Employer and take Affimative Action to recruit Protected Veterans and Individuals with Disabilities.”