Pharmacy Utilization Management Specialist

Point32Health, Inc.; Adams (MA); Hybrid; USD 34,000 - 50,000; Full time

Benefits offered by this job

Medical, dental and vision

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Job summary

Point32Health, Inc. is hiring a Pharmacy Utilization Management Specialist to set up and process drug prior authorization cases across multiple channels, ensuring regulatory compliance and timely turnaround.

The role requires a Certified Pharmacy Technician (CPhT) with at least 2 years of pharmacy experience, preferably in managed care/PBM settings, and proficiency in RxClaims and PAHub.

Qualifications

• High School Diploma or GED required; Associate's degree preferred.
• 2 years of pharmacy experience required; PBM/managed care experience preferred.

Responsibilities

• Set up cases for drug prior authorizations from fax, ePA, phone, and email.
• Perform full case review to meet regulatory and turnaround times.
• Document case notes for PAs needing pharmacist or medical director review.
• Run test claims for approved authorizations and contact members/providers as needed.
• Communicate with providers to process phone PAs and answer inquiries.
• Conduct daily quality checks and manage the Pharmacy UM email box and ePA requests.
• Support process improvements and participate in special projects.

Skills

MS Office

Prioritization

High accuracy

Attention to detail

Medical terminology

Independent & team

Judgement

Education

High School Diploma or GED

Associate's degree in Healthcare/Nursing/related

Tools

RxClaims

PAHub

Job description

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management (UM) Specialist is responsible for setting up and processing cases in the various applications for drug prior authorization (PA) requests.

Key Responsibilities/Duties - what you will be doing:

• Performs full case set up from fax, ePA, phone and email prior authorization requests
• Upon case set up, a full case review is performed ensuring all applicable regulatory and accreditation requirements and turnaround times are met
• Documents all relevant case notes for PAs (prior authorizations) requiring additional review by a pharmacist or medical director
• Run test claims for approved authorizations and reach out to members and providers as necessary
• Communicates with providers via department phone queue to process phone PAs and resolve provider inquiries
• Additional tasks include performing daily quality checks to ensure compliance, managing the Pharmacy UM team email box, responding to provider inquiries, managing electronic prior authorization (ePA) requests, submitting process improvements, among others
• Performs other roles/duties and projects as assigned

Qualifications - what you need to perform the job:

Certification and Licensure

• Certified Pharmacy Technician (CPhT)

Education

• Required (minimum): High School Diploma or GED. Associate's degree in Healthcare, Nursing, or a related area or equivalent experience.

Experience

• Required (minimum): 2 years of pharmacy experience
• Preferred: Experience in managed care/PBM setting. Software/Database experience - RxClaims, and PAHub

Skill Requirements

• Proficient in MS Office - Excel, Word, and PowerPoint Preferred
• Ability to prioritize work when processing medical and pharmacy drug PA requests per guidelines and within specific turnaround times
• Ability to process high volumes of requests with great accuracy
• Attention to detail and the ability to handle multiple demands, as well as balance multiple priorities in a fast-paced environment
• Good working knowledge of medical terminology
• Must be able to work independently, and as part of a team. Regular interface with various levels of staff and management is required.
• Must be able to exercise appropriate judgement as necessary, following all rules and regulations where required

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Some early mornings, evenings, weekends, or extended workday may be required as program dictates. Must have flexibility with work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$24.35 -$36.52

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all

All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.