Pharmacy Technician 1

Spectraforce Technologies, Inc.; Raleigh (NC); Remote; USD 23,000 - 32,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Pharmacy Technician 1 for a remote, contract-to-hire role. Training starts with a daytime EST schedule, then shifts to a Tue-Fri evening window and Saturday morning.

The position involves formulary management, audits, and Medicare/state program operations, working across multiple pharmacy functions to support patient benefits. The ideal candidate has a pharmacy tech license or license-eligibility, strong computer skills, and customer service

Qualifications

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

Responsibilities

• Reviews and processes formulary change requests and maintains status grids.
• Performs pharmacy audit and recovery tasks and communicates findings.
• Assists with member benefit questions and prior authorization processing.
• Supports Medicare Part D operations and state health program activities.

Skills

Strong computer skills

Customer service

Pharmacy technician experience

Education

High School diploma or GED

Job description

Position Title: Pharmacy Technician 1

Work Location: Remote

Assignment Duration: 6 months (Contract to Hire)

Work Schedule: Monday-Friday, 10:00 AM-6:30 PM EST during training (12-24 weeks). After training: Tuesday-Friday, 12:30 PM-9:00 PM EST; Saturday, 8:00 AM-4:30 PM EST.

Work Arrangement: Remote

Position Summary:

• 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.
• Using established company guidelines, the Pharmacy Technician reviews requests made by physicians, medical groups, pharmacies and members for the use of prescription drugs and pharmacy benefits. The technician researches and resolves questions, problems or issues. May consult with Clinical Pharmacists or Regional Medical Director on related issues.

Key Responsibilities:

Formulary Management

• Reviews and processes formulary change requests from The Organization plans.
• Submits and maintains formulary change requests to The Organization'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 The Organization 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 state health programs 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.
• State health programs 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 state health programs 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.

Qualification & Experience:

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

Candidate Requirements

Education/Certification - Required: High School diploma or GED required, Preferred:

Licensure - Required: Pharmacy Technician License, Preferred:

Years of experience required

Disqualifiers

Best vs. average

Performance indicators

Must haves: 1 year Pharmacy Technician experience

Nice to haves: Customer Service/retail experience preferred

Disqualifiers: Poor computer or time management skills

Performance indicators:

Top 3 must-have hard skills

• Strong computer skills
• Flexibility with changes
• Ability to meet production metrics

Level of experience with each

• 1
• Strong computer skills
• 2
• Flexibility with changes
• 3
• Ability to meet production metrics

Stack-ranked by importance

• 1
• Strong computer skills
• 2
• Flexibility with changes
• 3
• Ability to meet production metrics

Candidate Review & Selection

• 1
• Strong computer skills
• 2
• Flexibility with changes
• 3
• Ability to meet production metrics