Processes prior authorization requests in a timely manner and according to high quality standards.
Role and Responsibilities
· Technical review of authorizations (drug and utilization management) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation.
· Respond to prior authorization requests within compliance turnaround times and meeting quality standards regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
· Ensure that all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
· Communicate with providers (prescriber and pharmacy) on issues related to formulary, non-formulary criteria, or respective policies and procedures.
· Generates letters to members communicating PA outcomes, or if lack of response.
· Interface with IPM’s adjudication system, when necessary, in regards to adjudication and medication processing issues.
· Assist Clinical Pharmacist in review of Member’s medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments.
· Actively participate in internal quality improvement process enhancements.
· Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues.
· Ensure the privacy and security of PHI (Protected Health Information) as outlined in IPM's policies and procedures relating to HIPAA compliance.
· Other duties as assigned.
Qualifications and Education Requirements
· GED or equivalent
· California State Board Pharmacy License
· Pharmacy Technician Certification
· 3+ years of experience in Retail Pharmacy
Knowledge and Skills Required
· Microsoft Office experience
· Excellent organizational, written and verbal communication
· Highly motivated and good interpersonal skills, self-starter
· Ability to adapt and perform duties efficiently whenever unexpected changes arise
· Works well in a fast-paced environment
· Knowledge of pharmaceutical terminology
· Bachelor of Arts or Science degree from accredited college
· Prior Pharmacy Benefit Management preferred
· Strong Microsoft Excel skills preferred
· Project management skills preferred
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
This is a largely sedentary role; however some standing, walking, bending, and reaching may be required. Regularly operates a computer, mouse, keyboard, and occasionally operates other standard office equipment, such as printer, copier, phone.
Internal Number: CPAS2020
About Integrated Prescription Management
IPM full-service, middle market PBM committed to transforming the pharmacy benefit experience.
Known for our high-touch service, flexible benefit designs, and powerful analytics, IPM works with self-funded employer groups, brokers, TPAs, and behavioral health programs across the country.