JOB SUMMARY

Under the direction of the Director of Pharmacy Analytics, functions as a Pharmacy Program Specialist in the Pharmacy Analytics department. Provides efficient and accurate responses to external customers (physicians, office staff, pharmacy providers, members, and brokers), and internal team members. Resolves outpatient pharmacy benefit coverage and prescription claim problems. Communicates drug formulary guidelines, including drug formulary alternatives, prior authorization criteria, and group/member eligibility problems.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Assist with processing medication prior authorization and appeal requests within required turn-around time.
• Monitor and process medication override requests-Communicate authorization and medication approval to Pharmacy Benefit Manager within required turn-around time.
• Answer questions regarding pharmacy benefit and coverage of medical injectables under medical benefit.
• Resolve coverage issues with Pharmacy Benefit Manager pertaining covered drugs, copays, medication prior authorization requests and medication appeals.
• Make outreach to members and providers as directed to improve medication adherence.
• Assist with generating reports and perform monitoring over delegated PBM functions as directed.
• Make outreach to members and providers as directed to resolve issues with medical requests within required turn-around time.
• Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plan, and other duties as assigned.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: HS Diploma or GED required.
• Registered with the Texas State Board of Pharmacy as a pharmacy technician and in good standing (CPhT) required.
• Bachelors Degree preferred.
• Work Experience (Years and Area): Minimum of 1 year experience with a health plan or PBM in related functions
• Management Experience (Years and Area): N/A
• Software Proficiencies: Microsoft Office

Other: