Senior Pharmacy PBM Quality Review Technician

MCS Puerto Rico; San Juan (PR); On-site; USD 35,000 - 48,000; Full time

Job summary

MCS Puerto Rico is seeking a skilled Pharmacy Technician to perform comprehensive reviews of cases in PBM systems, ensuring accurate processing within Coverage and Organizational Determinations. The role focuses on compliance, data integrity, and timely handling of pre-authorization and appeal cases.

The candidate should hold an Associate Degree in Pharmacy Technician with a valid license, 2+ years in a Pharmacy Clinical unit, and knowledge of ICD-10 and CPT procedures.

Qualifications

• Associate degree in Pharmacy Technician required.
• 2+ years of experience in a Pharmacy Clinical unit preferred.
• Valid Pharmacy Technician License and Registration required.
• Knowledge of ICD-10 criteria and CPT procedures preferred.

Responsibilities

• Reviews cases flagged in processing systems for errors or incomplete information related to coverage and organizational determinations.
• Evaluates case classification (coverage/organizational determination or appeal) and prioritization (standard or expedited).
• Ensures data completeness and accuracy of fields completed by pharmacy technicians and case evaluations.
• Generates reports identifying misclassified Part D/pharmacy benefit cases and invalid formulary exceptions for the year.

Skills

Regulatory compliance

Quality review

Report generation

Process improvement

Attention to detail

Bilingual communication

Education

Associate Degree in Pharmacy Technician

Tools

Win Net

ICD-10 knowledge

CPT procedures knowledge

Job description

MCS Puerto Rico is seeking a skilled Pharmacy Technician to perform comprehensive reviews of cases in PBM systems, ensuring accurate processing within Coverage and Organizational Determinations. The role focuses on compliance, data integrity, and timely handling of pre-authorization and appeal cases.

The candidate should hold an Associate Degree in Pharmacy Technician with a valid license, 2+ years in a Pharmacy Clinical unit, and knowledge of ICD-10 and CPT procedures.