Pharmacy 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

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 ... 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)].

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.