Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:

Track and triage coverage determination requests submitted from providers and members to determine if a pharmacist review is required. Prepares detailed pharmacy prior authorization requests for review by pharmacist/physician reviewers. Completes pharmacy authorization requests and issues review outcome notifications to Driscoll Health Plan members and providers. Follows clinical criteria and instructions to approve prior authorization requests based on established criteria, plan policies and procedures. Reviews medication utilization reports and identifies trends.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the DHP Administrator as required.

General Responsibilities:

Pharmacy Technician Responsibilities:

Determines eligibility and screens incoming pharmacy prior authorization requests, appeals, and grievances for all required documents using established procedures for multiple lines of business. Prepares, organizes, and distributes these requests for review by Director of Pharmacy or Medical Director and responds to pharmacist/physician reviewers’ requests for additional information. Completes prior authorizations related to clinician administered drug (CAD) claims in the Medical Management System and provides authorization details to service providers. Issues oral and written CAD prior authorization outcome notifications that comply with standards and requirements for timeliness, content and accuracy. Processes all pharmacy authorization requests unresolved by the Pharmacy Benefit Manager (PBM) working closely with the Director of Pharmacy. Acts as a provider help desk specialist to aid providers in submitting prior authorization requests, providing formulary product information, and communicating prior authorization request status. Contacts providers to resolve questions, obtain information, medical records and/or other pertinent information as needed. Assist member services representatives with medication related issue resolution, follow up, or referral to the appropriate department in a timely and efficient manner. Follows-up on unresolved authorization requests. Keeps Director of Pharmacy informed of concerns or complex issues that require further review. Coordinates monthly reports for clinical review by Director of Pharmacy. (PMUR, RDUR triple threat, BH med to bed discharges, 72 emergency fills, asthma adherence/education, specialty adherence rates) Reports findings from quarterly audit of PBM and pharmacy processes to assure regulatory compliance. Facilitates communication among departments, members and involved healthcare providers to promote a full understanding and achievement of mutually set goals. Applies utilization management (UM) policies to maintain compliance with all regulatory requirements. Demonstrates adherence to policies and procedures set forth by DHP. Appropriately identifies and refers quality concerns, long term case management candidates, and cases requiring medical director review to the appropriate area in a timely manner. Participates in Quality Improvement Teams (QIT), organizational committees and projects. Identifies and reports high-cost medications that exceed thresholds to the reinsurance carrier. Performs other duties as assigned. Demonstrates competence to perform assigned patient care responsibilities in a manner that meets the age-specific and developmental needs of patients served by the department. Appropriately adapts assigned patient assessment, treatment and/or care methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each patient served. Supports DHP mission, vision and values. Demonstrates established customer service behaviors and standards. Treats all customers with courtesy, dignity, respect and professionalism.

Core Competencies/knowledge & skill requirements

Education and/or Experience:

Graduation from high school/GED required or equivalent experience is required. Some coursework at the college level is preferred. Excellent customer service, phone etiquette, attention to detail, and typing skills is required. Basic knowledge of Microsoft Office and internet required. Experience in health insurance/pharmacy insurance or managed care organization preferred. Prior authorization processing experience desired. Experience in a PBM or managed care call center desired. Knowledge of InterQual screening criteria as well as DRG, ICD-10 and CPT coding is preferred.

Certificates, Licenses, Registrations.

Texas State Board of Pharmacy registration required. Certification as a Pharmacy Technician (CPhT) is required