Under the general supervision of the Supervisor of Pharmacy Prior Authorization Technicians, the Pharmacy Services Technician I assist in the prior authorization process.
* Assists Pharmacy Prior Authorization Supervisor in the daily activities of the pharmacy prior authorization process involving clinical decisions and issues.
* Works with Supervisor in responding to internal and external audits.Pulls requested files and reviews for completeness.Identifies deficiencies and notifies Supervisor of missing/incomplete information.Follows up with staff to correct information and bring files into compliance.Prepares and mails requested audit data to appropriate parties within established timeframes.
* Conducts internal quality assurance audits (e.g. member appeals, prior authorization status, turnaround statistics, etc.).Provides Supervisor with audit results for review and action.Assists in the implementing and tracking changes to internal processes and procedures.
* Reviews and approves physician inquiries for pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
* Supports Fraud and Abuse program system oversight by reviewing medication utilization records.Communicates any suspected fraud discovered.Recommends course of action for providers where patterns appears outside of guidelines and generally accepted pharmacy standards.
* Keeps abreast of industry trends and regulatory changes in the pharmacy industry and incorporates knowledge in the performance of job duties.Identifies problems in process/procedures or services and makes recommendations for improvements. Maintains a balance of productivity, quality and timeliness of job accountabilities.Participates in department self-audit procedures for on-going evaluation of service.
* Maintains and updates internal databases.Enters application information, prior authorizations and other relevant data.Ensures database information and appended files are current and accessible to staff.Generates reports and other information requested on a scheduled/as needed basis.
* Creates and supports an environment which fosters teamwork, cooperation, respect and diversity.Establishes and maintains positive communication and professional demeanor with internal and external business partners at all times.
* Performs other related duties as assigned.
* Attends required training on an annual basis.
* Adheres to AMFC policies and procedures.
* High School/GED.
* Current PTCB or NCCT certificate.
* Previous PBM, managed care, hospital pharmacy, LTC pharmacy, Home Infusion pharmacy, retail pharmacy experience preferred.