About the position
The Initial Review Pharmacy Technician plays a crucial role in the medical and pharmacy management initiatives that are essential for Prime Therapeutics to achieve its revenue goals and operational objectives. This position is responsible for executing utilization management programs on behalf of health plan and payor customers, utilizing clinical knowledge related to a specific list of managed medications across all health plans. The technician will undergo additional training for each medication and therapeutic class to ensure they are well-equipped to handle the responsibilities of the role. The primary activities of this position involve reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. This includes making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information necessary for determining medication reimbursement. Recommendations made by the technician will be based on a thorough understanding of specific specialty medications and industry guidelines, applicable to both pre- and post-service requests. The technician will also coordinate with various internal departments, including operations, clinical, medical, and reporting, as needed. In this role, the technician will review pertinent patient information and assess appropriateness using clinical criteria, making approval recommendations for all services that meet these criteria. Cases that do not meet clinical criteria will be referred to a pharmacist clinical reviewer. The technician is expected to practice and maintain the principles of utilization management by adhering to company policies and procedures, ensuring the clinical integrity of pharmaceutical solutions through ongoing training programs that comply with applicable standards and regulations. The technician will conduct Program Integrity Audits, which include outreach and review of medical records to verify the authenticity of provider responses during Prior Authorization, reporting results to clients. Additionally, the technician will assist in documenting and implementing both written and verbal communications to physicians and prescribers, as well as maintaining the edits and data elements that support these edits. They will be available for consultation on pharmacy-related questions to resolve claims submission issues related to medication edits. The technician will contact physicians and prescribers to obtain relevant clinical history and information, providing optimum customer service through professional and accurate communication while adhering to NCQA and health plan-required timeframes. Regular monitoring of information on pended claims identified as outliers by internal or external analysis of pharmacy claims data will also be part of the responsibilities. The technician may support intake call volume and order entry as necessary, determine eligibility for medication reimbursement based on established clinical criteria, and document communications electronically with physicians, their staff, cardholders, and pharmacies. In cases where further review is necessary, medical exception requests will be escalated to a nurse, pharmacist, or physician on the utilization review clinical team. Other duties may be assigned as needed.
Responsibilities
- Review pertinent patient information and check appropriateness using clinical criteria.
- Make approval recommendations on all services that meet clinical review criteria.
- Refer all cases not meeting clinical criteria to pharmacist clinical reviewer.
- Practice and maintain the principles of utilization management by adhering to company policies and procedures.
- Uphold clinical integrity of pharmaceutical solutions by participating in ongoing training programs.
- Conduct Program Integrity Audits including outreach and review of medical records.
- Assist with documentation and implementation of communications to physicians/prescribers.
- Maintain edits and data elements that support the edits.
- Provide consultation in pharmacy-related questions to resolve claims submission issues.
- Contact physicians/prescribers to obtain pertinent clinical history/information.
- Provide optimum customer service through professional communication.
- Regularly review and monitor information on pended claims identified as outliers.
- Support intake call volume and order entry if necessary.
- Determine eligibility for medication reimbursement based on established clinical criteria.
- Electronically document communications with physicians, staff, cardholders, and pharmacies.
- Escalate medical exception requests to the clinical team when further review is necessary.
Requirements
- Must have an active pharmacy technician licensure or registration in accordance with state requirements.
- If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or registration and an active national certification (e.g., PTCB or ExCPT).
- In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT).
- Minimum of 2 years of pharmacy experience without a Bachelor's degree OR 2 years of pharmacy experience with a Bachelor's degree in Science, Health, Medical or related field.
- Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting.
- Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment.
- Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems.
- Strong team orientation with respect for all members.
- Excellent verbal and written communications skills.
- People skills essential for successful consultation with physicians, prescribers, and pharmacists.
- Analytic skills that can translate into practical recommendations.
- In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques, and medical terminology.
- Oncology pharmacy or other clinical pharmacy experience.
- 4 years of pharmacy experience.
Benefits
- Competitive pay ranging from $22.84 - $34.25 based on experience and skills.
- Comprehensive health insurance coverage.
- 401k retirement savings plan with company matching contributions.
- Paid time off and holidays.
- Tuition reimbursement for further education.
- Professional development opportunities.
- Employee discounts on various services and products.
