[Hiring] Pharmacy Utilization Management Specialist @Point32Health

Role Description

Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management (UM) Specialist is responsible for setting up and processing cases in the various applications for drug prior authorization (PA) requests.

Key Responsibilities/Duties

• Performs full case set up from fax, ePA, phone and email prior authorization requests.
• Upon case set up, a full case review is performed ensuring all applicable regulatory and accreditation requirements and turnaround times are met.
• Documents all relevant case notes for PAs (prior authorizations) requiring additional review by a pharmacist or medical director.
• Run test claims for approved authorizations and reach out to members and providers as necessary.
• Communicates with providers via department phone queue to process phone PAs and resolve provider inquiries.
• Additional tasks include performing daily quality checks to ensure compliance, managing the Pharmacy UM team email box, responding to provider inquiries, managing electronic prior authorization (ePA) requests, submitting process improvements, among others.
• Performs other roles/duties and projects as assigned.

Qualifications

• Certification and Licensure: Certified Pharmacy Technician (CPhT)
• Education: Required (minimum): High School Diploma or GED. Associate's degree in Healthcare, Nursing, or a related area or equivalent experience.
• Experience: Required (minimum): 2 years of pharmacy experience. Preferred: Experience in managed care/PBM setting. Software/Database experience - RxClaims, and PAHub.
• Skill Requirements:
  • Proficient in MS Office - Excel, Word, and PowerPoint Preferred.
  • Ability to prioritize work when processing medical and pharmacy drug PA requests per guidelines and within specific turnaround times.
  • Ability to process high volumes of requests with great accuracy.
  • Attention to detail and the ability to handle multiple demands, as well as balance multiple priorities in a fast-paced environment.
  • Good working knowledge of medical terminology.
  • Must be able to work independently, and as part of a team. Regular interface with various levels of staff and management is required.
  • Must be able to exercise appropriate judgement as necessary, following all rules and regulations where required.

Requirements

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Some early mornings, evenings, weekends, or extended workday may be required as program dictates. Must have flexibility with work schedule.

Benefits

• Medical, dental and vision coverage.
• Retirement plans.
• Paid time off.
• Employer-paid life and disability insurance with additional buy-up coverage options.
• Tuition program.
• Well-being benefits.
• Full suite of benefits to support career development, individual & family health, and financial health.