Pharmacy Technician

Triple-S; Guaynabo (PR); On-site; USD 32,000 - 42,000; Full time

Job summary

Triple-S in Puerto Rico seeks a Pharmacy Technician to handle Coverage Determination in the Pharmacy Department, ensuring compliance with CMS, ASES, URAC, and state requirements. You will gather clinical information, liaise with physicians, pharmacies, and enrollees, and document decisions for timely responses.

The role emphasizes accuracy in plan decisions, adherence to regulatory criteria, and effective communication with stakeholders to support patient access to medications and services.

Qualifications

• Pharmacy Technician course and one year of experience.
• Active, unrestricted Pharmacy Technician license in Puerto Rico.
• Ability to communicate with physicians, pharmacies, and enrollees.
• Compliance with CMS, ASES, URAC, and state laws.

Responsibilities

• Evaluate Coverage Determination requests and classify them per CMS and internal policies.
• Gather clinical information to support evaluations.
• Contact physicians, pharmacies, or enrollees to obtain needed information.
• Document all efforts in the system and communicate final decisions.
• Prepare letters to inform parties of decisions.
• Provide orientation on Coverage Determination and Appeals processes.
• Notify status via outbound calls to stakeholders.
• Ensure clinical accuracy of plan decisions with regulatory criteria.
• Identify trends in complaints and assist in action plans.

Skills

Pharmacy procedures

Clinical data collection

Customer service

Education

Technical Course in Pharmacy

Lic. Pharmacy Technician

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

Accountable for receiving, referring and responding all requests received in the Pharmacy Department related to Coverage Determination for all line of business applying the criteria and guidelines approved by CMS, ASES, URAC, “Comisionado de Seguros”, federal requirements and other regulatory state laws.

Essential Functions

• Evaluate requests received for Coverage Determination, properly classifies the request and handle it through the process distinguishing between coverage determination, grievances and appeals processes in accordance to the regulations and following Triple-S policies and procedures.
• Gathers the necessary clinical information required to complete the evaluation of the case according HUM1 established criteria.
• Contact physician, pharmacy and, or enrollee if further information is required to complete the evaluation and, or to obtain information necessary to make an appropriate clinical decision.
• Deliver the information to Pharmacist so she or he can make a timely decision using the clinical criteria approved.
• Documents all efforts for investigating, resolving and responding to the cases in the system according to the line of business.
• Prepare letter to request information or to inform the final decision to pharmacy, physician and enrollee or authorized representative.
• Offer orientation to pharmacy, physician and enrollee or authorized representative related to the Coverage Determination and Appeals processes.
• Make calls to notify the status of the request to pharmacy, physician and, or enrollee or authorized representative.
• Receive calls and inquiries from pharmacies and customer services department.
• Make outbound calls to enrollee or authorized representative for adherence drugs to comply with CMS Stars Measures.
• Responsible for ensuring the clinical accuracy of plan decision-making, including adherence to Medicare, Medicaid, Commercial and, or Federal and plan coverage criteria. This includes ensuring all Coverage Determination and Appeals involving medical necessity are made by an appropriate physician and, or pharmacist.
• Identify and refer to the management any trends in complaints categories, area of opportunity and assist in the development of any action plan for immediate and effective reduction of complaints.

Education

• Technical Course in Pharmacy

Experience

• Pharmacy Technician Course with one (1) year of experience as a Pharmacy Technician.
• Hold an active, unrestricted professional license to practice as a Pharmacy Technician in Puerto Rico state law of Puerto Rico Board of Pharmacy [HUM 15 b (i)].

LICENSES AND CERTIFICATIONS

• Lic. Pharmacy Technician

COMPETENCIES

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.