Senior PBM Pharmacy Technician – Quality & Compliance

MCS Health; San Juan (PR); Sur place; USD 55 000 - 75 000; Plein temps

Résumé du poste

MCS Health in San Juan, Puerto Rico, seeks a Pharmacy Technician to conduct comprehensive reviews of PBM cases within quality review trays, ensuring accurate handling per Coverage and Organizational Determinations policies.

The role requires 2+ years in a Pharmacy Clinical unit, an active Pharmacy Technician License, and knowledge of ICD-10/CPT. Spanish and English proficiency are expected.

Qualifications

• Requires an Associate Degree in Pharmacy Technician with 2+ years in a Pharmacy Clinical unit.
• Experience with coverage and organizational determinations, appeals processing, regulatory compliance, quality review, and process improvement preferred.

Responsabilités

• Reviews cases flagged in processing systems for errors or incomplete information related to coverage and organizational determinations.
• Identifies and resolves missed cases within the PBM adjudication system to ensure accurate processing.
• Evaluates each case for proper classification (coverage/OD or appeal), prioritization (standard or expedited), decision outcomes, and denial letter accuracy.
• Validates completeness and correctness of all fields completed by pharmacy technicians and the corresponding case evaluations.
• Generates reports identifying cases requiring pre-authorization and flags formulary exceptions invalid for the calendar year.
• Ensures data matching between mailed letters and system records (date/time) in Win Net.
• Facilitates reassignment of cases received via fax, web, or ePA among Pharmacy Technicians.
• Supports supervisors with retraining on updates and regulatory changes.
• Monitors audit-related reports and takes necessary actions.
• Contributes to updating operational guidelines, policies, and procedures.
• Assists in evaluating and reviewing applications for business lines when needed.

Connaissances

Pharmacy operations

Regulatory compliance

Quality review

Report generation

Appeals processing

Process improvement

Coverage/OD determinations

Formation

Associate Degree in Pharmacy Technician

Outils

Win Net

Description du poste

MCS Health in San Juan, Puerto Rico, seeks a Pharmacy Technician to conduct comprehensive reviews of PBM cases within quality review trays, ensuring accurate handling per Coverage and Organizational Determinations policies.

The role requires 2+ years in a Pharmacy Clinical unit, an active Pharmacy Technician License, and knowledge of ICD-10/CPT. Spanish and English proficiency are expected.