Pharmacy Technician

Centene Corporation; United States; Hybrid; USD 36,000 - 48,000; Full time

Benefits offered by this job

Health insurance

401K

Stock options

Tuition reimbursement

Paid time off

Flexible work schedules

Job summary

Centene Corporation is seeking a Pharmacy Technician to support formulary management, claims processing, and clinical audit tasks. You will review formulary changes, assist with prior authorizations, and handle member benefit questions while maintaining regulatory compliance.

You will contribute to Medicare Part D operations and SHP processes, ensuring accurate documentation and efficient service delivery across multiple health programs.

Qualifications

• High School diploma or GED required.
• 1 year Pharmacy Technician experience required.
• Customer Service/retail experience preferred.

Responsibilities

• Reviews and processes formulary change requests from Health Net plans.
• Submits and maintains formulary change requests to Health Net’s pharmacy claims processor.
• Generates, maintains and reviews Formulary Status Grids.
• Uses reports to perform audits and quality checks on formulary status for accuracy and contract compliance.
• Assists Clinical Pharmacist with formulary database maintenance and website updates.
• Performs pharmacy audit and recovery tasks including reviewing paid claims for discrepancies.
• Handles member inquiries including benefit questions and prior authorizations.
• Reviews requests for non-formulary drugs and documents authorizations accordingly.
• Assigns and documents prior authorizations in claims systems.
• Tracks PDE files and participates in prescription coverage determinations.

Skills

Customer service

Pharmacy terminology

Education

High School diploma or GED

1 year Pharmacy Technician experience

Customer Service/retail experience preferred

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

• Reviews and processes formulary change requests from Health Net plans
• Submits and maintains formulary change requests to Health Net’s pharmacy claims processor
• Generates, maintains and reviews Formulary Status Grids
• Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance
• Assists Clinical Pharmacist with formulary database maintenance and updates to company web site

Pharmacy Audit and Recovery:

• Performs a variety of assignments required for pharmacy audit and recovery functions
• Reviews paid claims for quantity and/or billing discrepancies. Corresponds with pharmacies as needed to communicate review finding
• Faxes inquiries to pharmacies related to review findings
• Answers in-coming calls and responds appropriately to faxed correspondence from pharmacies
• Updates Access database with incoming phone calls, faxes and e-mails

Pharmacy Services Center:

• Takes member inquiry calls for benefit questions including prior authorization requests
• Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position
• Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request
• Process member submitted claims

Prior Authorization:

• Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim
• Assign, enter and document prior authorizations into appropriate claims processing system
• Answer phone calls for prior authorization inquiries
• Researches and resolves issues using the appropriate reference material
• Responsible for knowing and interpreting pharmacy and medical benefits

Medicare Part D Operations:

• Reviews and processes PDE files
• Researches and resolves issues using the appropriate reference material
• Assists in pharmacy claims corrections projects
• Performs audits and quality checks on active prior authorizations claims
• Assists with identifying and correcting eligibility and group issues
• Processes member claims

State Health programs Pharmacy Operations:

• Liaison to internal and external departments for SHP pharmacy
• Operational issue resolution, including issues from Prior Auth, Appeals and Grievances, and Member/Provider Services
• Preparation and review of various operational reports and audits
• SHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenance
• Maintenance of prior authorization database files
• Medi-Cal DMR processing
• Assist with SHP clinical projects
• Assist with Medi-Cal prior authorizations

Oversight and Audit Support:

• Assists in the implementation of regulatory changes
• Participates in maintaining consistent processes/methods for development, implementation, communication and training on new/updated policies and procedures
• Participates with Business Units/departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into P&Ps that span multiple departments
• Provides support and monitoring to ensure compliance of First Tier, Downstream and Related Entities (FDRs)
• Assists with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)

Appeals:

• Identifies validity of appeal.
• If not a valid appeal, be able to send request to correct department
• Verifies drug, dosage, quantity, provider, diagnosis information
• Research using formularies and prior authorization criteria to verify if additional information is needed.
• If additional information is needed, reach out to providers and members and communicating clearly what information is needed
• Other appeal tasks as assigned

Prior Authorization Medicare Part D and Part B:

• Tracks and triage coverage determination and/or prior authorization requests submitted from providers and determine if a pharmacist review is required
• Obtains verbal authorizations and request detailed clinical information from prescribers
• Approves coverage determination and/or prior authorization requests based on defined criteria
• Enters and documents coverage determination and/or prior authorization request decisions into the PBM system and notify providers and/or members
• Responds to client inquiries regarding authorization approvals and PBM online applications
• Refers coverage determination requests for specialty drugs to delegated vendor or client for processing
• Contacts providers for additional information to facilitate coverage determination reviews
• Notifies physicians, providers, and members of coverage determination request decisions
• Performs other duties as assigned
• Complies with all policies and standards

The Pharmacy Technician may perform duties in one or more of the following areas:

Formulary Management, Pharmacy Audit and Recovery, Pharmacy Service Center, Medicare Part D/Part B, Appeals, Medicare Part D Operations and State Health Programs Pharmacy Operations or Prior Authorization.

Education/Experience:

High School diploma or GED required. 1 year Pharmacy Technician experience. Customer Service/retail experience preferred

License/Certification:

Valid Pharmacy Technician License preferred.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act