Initial Review Pharmacy Technician
Company: Magellan Health
Posted on: October 13, 2021
Plays a key role in medical and pharmacy management initiatives
critical to the company achieving revenue goals and operational
objectives. Responsible for executing utilization management
programs on behalf of health plan/payor customers, while utilizing
additional clinical knowledge pertaining to a set list of managed
medications across all health plans, with additional training for
each medication and therapeutic class. Primary activities center on
reviewing both prospective and retrospective requests for
therapeutic appropriateness using sound clinical criteria.
Responsible for making and receiving calls to and from physicians,
patients, and pharmacies to gather additional clinical information
to determine medication reimbursement. Recommendations will be
based on an in-depth understanding of specific specialty
medications and industry guidelines, on both pre- and post-service
requests. Coordinates with operations, clinical, medical, reporting
and other internal departments as needed.
- Reviews pertinent patient information and checks
appropriateness using clinical criteria. Makes approval
recommendations on all services that meet clinical review criteria.
Refers all cases not meeting clinical criteria to pharmacist
- Practices and maintains the principles of utilization
management by adhering to the company policies and
procedures. Upholds clinical integrity of pharmaceutical
solutions by participating in on-going training programs to ensure
quality performance in compliance with applicable standards and
regulations. Expert within the organization.
- Conducts Program Integrity Audits including outreach and review
of medical records to audit authenticity of provider response
during Prior Authorization and reporting results to client.
- Assists with the documentation and implementation of both
written and verbal communications to physicians/prescribers and
assists in the maintenance of the edits and data elements that
support the edits.
- Available for consultation in pharmacy related questions
to resolve claims submission related to medication
- Contacts physicians/prescribers to obtain pertinent clinical
history/information. Provides optimum customer service
through professional/accurate communication while maintaining NCQA
and health plan`s required timeframes.
- Regularly reviews and monitors information on pended claims
identified as outliers by internal and/or external analysis of
pharmacy claims data.
- Supports Intake call volume and order entry if necessary.
- Determines eligibility for medication reimbursement based upon
established clinical criteria and clinical knowledge and enters
approvals or denials in the system.
- Electronically documents both written and verbal communications
with physicians, their staff, cardholders, and pharmacies.
- Escalates medical exception requests to nurse, pharmacist or
physician on the utilization review clinical team when
further review is necessary.
- Other duties as assigned.
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
in accordance with state requirements 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 5 years of pharmacy experience without a Bachelors
degree OR 2 years of pharmacy experience with a Bachelors
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
Experience as Pharmacy Technician, Utilization Management or
Customer Service in a high-volume, multi-functional call center
Must be comfortable with using computers and the internet; basic
skills with Microsoft office products and ability to quickly learn
proprietary systems, typing.
Strong team orientation with respect for all members.
Excellent verbal and written communications skills.
People skills are essential that allow for the successful
consultation with physicians, prescribers and pharmacists and for
successful collaboration with company employees and external
vendors who do not directly report to this position.
Analytic skills which can translate into practical and pragmatic
In-depth knowledge of specialty injectable prescription drugs,
disease states, health plan formulary management techniques and
medical terminology., Oncology pharmacy or other clinical pharmacy
Initial Review Pharmacy Technician
Work Experience - Required
Work Experience - Preferred
Education - Required
Education - Preferred
A Combination of Education and Work Experience May Be Considered.,
Certifications - Required
CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements -
Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity
Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the
security responsibilities and security controls unique to their
position; and comply with all applicable legal, regulatory, and
contractual requirements and internal policies and procedures.
Keywords: Magellan Health, Orlando , Initial Review Pharmacy Technician, Other , Orlando, Florida
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