The Pharmacy Technician may perform duties in one or more of the following areas: Formulary Management, Pharmacy Audit and Recovery, Pharmacy Service Center or Prior Authorization, Medicare Part D Operations and State Health Programs Pharmacy Operations.
Using established company guidelines, the Pharmacy Technician reviews requests made by physicians, medical groups, pharmacies and members for the use of prescription drugs and pharmacy benefits. The technician researches and resolves questions, problems or issues. May consult with Clinical Pharmacists or Regional Medical Director on related issues.
Essential Duties & Responsibilities
- Demonstrates regular, reliable and predictable attendance.
- Formulary Management:
- Reviews and processes formulary change requests from Health Net plans
- Submits and maintains formulary change requests to Health Net's pharmacy claims processor
- Generates, maintains and reviews Formulary Status Grids
- Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance
- Assists Clinical Pharmacist with formulary database maintenance and updates to company web site
- Pharmacy Audit and Recovery:
- Performs a variety of assignments required for pharmacy audit and recovery functions.
- Reviews paid claims for quantity and/or billing discrepancies. Corresponds with pharmacies as needed to communicate review finding.
- Faxes inquiries to pharmacies related to review findings
- Answers in-coming calls and responds appropriately to faxed correspondence from pharmacies
- Updates Access database with incoming phone calls, faxes and e-mails
- Pharmacy Services Center:
- Takes member inquiry calls for benefit questions including prior authorization requests
- Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position.
- Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request.
- Process member submitted claims.
- Prior Authorization:
- Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim.
- Assign, enter and document prior authorizations into appropriate claims processing system.
- Answer phone calls for prior authorization inquiries
- Researches and resolves issues using the appropriate reference material.
- Responsible for knowing and interpreting pharmacy and medical benefits.
- Medicare Part D Operations
- Reviews and processes PDE files
- Researches and resolves issues using the appropriate reference material
- Assists in pharmacy claims corrections projects
- Performs audits and quality checks on active prior authorizations claims
- Assists with identifying and correcting eligibility and group issues
- Processes member claims
- State Health programs Pharmacy Operations
- Liaison to internal and external departments for SHP pharmacy
- Operational issue resolution, including issues from Prior Auth, Appeals and Grievances, and
- Member/Provider Services
- Preparation and review of various operational reports and audits
- SHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenance
- Maintenance of prior authorization database files
- Medi-Cal DMR processing
- Assist with SHP clinical projects
- Assist with Medi-Cal prior authorizations
High School diploma or GED required
Valid Pharmacy Technician License
Government Clearance & US Citizenship Requirement
Two years Pharmacy Technician experienceCustomer Service/retail experience preferredORAny combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Knowledge, Skills & Abilities
Working knowledge of pharmaceutical claims, language, drug usage and generic substitution practicesComputer skills and working knowledge of Microsoft products, claims processing software and report creationAbility to learn new software applicationsAccurate typing of 30 wpmExcellent verbal and written communication skillsProfessional telephone etiquette and skillsFamiliarity with Formulary Lists including common edits and restrictionsExcellent organization skills
- The following section describes the general physical requirements for this position. Please note that constant refers to more than 81% of time; significant refers to 40-80%; and moderate refers to 20-40% of the time.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Constant phone usage; headsets may be required.
- Significant amount of time spent working in a loud office environment with frequent interruptions/distractions.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this job. They are not intended to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified.
Location: Rancho Cordova
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
Health Net and its subsidiaries are an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Veterans/Disability