Description
Who We Are - Motivated by Purpose. Powered by Clinical Expertise.
Founded in 1983, we’re a clinically-driven, tech-enabled utilization management company offering expert clinical reviews, regulatory guidance, and actionable insights to healthcare organizations.
Excellence starts with our people.
WE OFFER
- A competitive compensation package.
- Benefits include healthcare, vision and dental insurance, a generous 401k match, paid vacation, personal time, and holidays.
- Growth and training opportunities.
- A team atmosphere with fun events and prizes scheduled throughout the year.
Position Summary
- Our Clinical Pharmacy Technician processes prior authorization requests in accordance with standards for accuracy, timeliness, productivity, and client performance commitments.
- Performs analysis, obtains information, and enters prior authorization data necessary for claims adjudication. Utilizes reasoning skills to identify missing information and make prior authorization processing determinations based on clinical protocols and client guidelines (approve, pend, refer for clinical decision, etc.).
- Interacts with internal and external customers to provide and obtain information and ensures the delivery of outstanding service and quality.
Roles
- Process and finalize PA requests within clients’ turnaround time (TAT) and Performance Guarantees (PGs) utilizing guidelines.
- Accountable for achieving prior authorization processing productivity and accuracy standards
Major Responsibilities or Assigned Duties
- Enter prior authorizations into the system and prioritize requests.
- Check formulary alternatives and review tried and failed medications.
- Utilize drug references and verify the drug being requested is indicated and approved for the condition.
- Document all related information regarding the PA approval or non-approval.
- Conform to defined roles & responsibilities and rules of engagement between prior authorization processing and clinical decision-making. Partner with assigned clinical pharmacists to ensure strict adherence to the boundaries and timeframes of administrative processing.
- Analyze, research, and resolve prior authorization processing issues, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from supervisor or clinical pharmacists; and referring unique or high dollar requests to supervisor according to guidelines.
- Coordinate within client system outbound communication to members, physicians, and pharmacies as required to obtain missing information and manage pending requests.
- Document prior authorization-related information and status.
- Make outbound calls to obtain information and answer questions about prior authorization status.
- Protect and maintain confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.
- Identify and recommend operational improvements.
- Participate in and support all applicable Quality Management initiatives
- Maintain a flexible schedule to meet client needs, as needed
- Adhere to all policies and procedures
- Take feedback and responsibility for performance
- Adapt to the differences of clients
- Support all Compliance Program activities
- Complete other duties and responsibilities as directed
Position Levels
Each level attained compounds responsibilities with those of prior level(s).
Clinical Pharmacy Technician I:
- Production should increase regularly, from 1-3 to 7 Prod steps/hour
- Quality should increase regularly, with expected minimum rate of 95%
Clinical Pharmacy Technician II:
- 3-month Production average should meet or exceed 7 Prod steps/hour (100%)
- 3-month Quality average should meet or exceed 96%
- No PIPs or CAPs in prior 3 months for any reason
- Completed all training checklists for department and demonstrated proficiency with position processes and PG clients
- Participate in the weekend rotation process
- Proficient with all position processes and team clients’ expectations
- Demonstrate ability to create training documents/presentations
Clinical Pharmacy Technician III:
- 3-month Production average should meet or exceed 8.3 Prod steps/hour (118%)
- 6-month Quality average should meet or exceed 98%
- No PIPs or CAPs in prior 6 months for any reason
- Effectively manage PANF reports, daily assignments, LOI, and Outreach calls
- Demonstrate problem solving and ability to work cross-functionally for new projects and HQs
- Demonstrate ability to train other PACs on HQ/processes and provide constructive feedback
- Effectively assist with monthly audits when asked
- Correctly approve PAC I-II Overdollar requests, as well as own
- Participate in special projects, lead committees, or pilot new processes/improvements
Clinical Pharmacy Technician IV:
- 3-month Production average should meet or exceed 9.7 Prod steps/hour (138%)
- Effectively regularly assist with monthly audits and calibration calls
- Cross trained on RxAdvance process/system and capable of filling in at any time
- Participate in the weekend rotation and weekend leadership on-call process
- Effectively train and mentor new hires from day 1 overview to end of 120 days, including weekly training meetings
- Participate in the Customer Advocate Program
- Effectively cover the floor without a supervisor, including for escalated calls or emails
Requirements
Skills and Experience
- Ability to work in a fast-paced and high-functioning environment and meet deadlines while managing multiple high priorities.
- Moderate-to-high level of medication and disease state knowledge within the scope of pharmacy practice
- Personal computer literacy and high competency in using Microsoft Word, Excel, Adobe, etc.
- Strong organizational skills with attention to detail
- Strong oral and written communication skills
- Excellent critical thinking capabilities with a strong attention to detail
- Exceptional customer service skills
- Minimum one-year prior authorization experience preferred
- Health plan or Pharmacy Benefit Manager experience preferred
Education
- High school diploma or equivalent
- Active Certified Pharmacy Technician (State or National License)
Work Environment:
Ability to sit at a desk, utilize a computer, telephone, and other basic office equipment is required. This role is designed to be a remote position (work-from-home).
Diversity Statement:
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
Drug-Free Workplace:
This company is a drug-free workplace. All candidates are required to pass a Background Screen before beginning employment. All newly hired employees will take a Drug Screen, as well as agreeing to all necessary Compliance Regulations on their first day of employment. Employees are required to adhere to all applicable HIPAA regulations and company policies and procedures regarding the confidentiality, privacy, and security of sensitive health information.
California Consumer Privacy Act (CCPA) Information (California Residents Only):
- Sensitive Personal Info: MRIoA may collect sensitive personal info such as real name, nickname or alias, postal address, telephone number, email address, Social Security number, signature, online identifier, Internet Protocol address, driver’s license number, or state identification card number, and passport number.
- Data Access and Correction: Applicants can access their data and request corrections. For questions and/or requests to edit, delete, or correct data, please email the Medical Review Institute at HR@mrioa.com.
