Description:
*THIS IS A CALL CENTER & CANDIDATE NEEDS TO BE AWARE THAT THEY WILL BE TAKING INBOUND CALLS IN A HIGH VOLUME CALL CENTER*

Evaluates and authorizes approval of prior authorization pharmacy requests from prescribers received by telephone and/or facsimile using client clinical criteria.

ESSENTIAL FUNCTIONS:
- Determines appropriateness for medications. Communicates decision to physicians, physician's office staff, medical management staff and/or pharmacists.
- Researches, resolves and documents prior authorization outcomes in pharmacy system.
- Communicates selected prior authorization criteria, pharmacy benefit coverage and formulary alternatives to physicians, physician's office staff, medical management staff and/or pharmacists.
- Escalates requests to Pharmacist when request requires extensive clinical review or denial.
- Researches, resolves and documents physician or client inquiries and grievances and provides verbal or written results to client, prescriber, provider and/or management.
- Performs other duties as required.
-Ability to identify and trouble-shoot problematic issues.

Requirements/Certifications:
-PTCB: Certification REQUIRED
-Specialty or retail pharmacy industry experience, previous reimbursement experience, and/or working in a health plan/health care setting.
-In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques, medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-9, CMS 1500, etc.).
-Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.
-Excellent written and verbal communication skills.
-Ability to follow clinical criteria and instructions to approve prior authorization requests.
-Minimum of 6 months dispensing or retail experience required, or equivalent internal training will be substituted.
-Ability to identify and trouble-shoot problematic issues.
***CANDIDATE WILL NEED TO BE AVAILABLE TO WORK ANY SHIFT MONDAY - SUNDAY; 9:00 AM-8:30 PM. WILL HAVE 2 DAYS OFF. **

All your information will be kept confidential according to EEO guidelines.