Location: Philadelphia, PA 19113.
Job Description:
- Reviews physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria. Forwards initial denials to appropriate queue for further review. Generates notification letters to members and physicians on approved and denied requests.
- Handles calls and correspondence from providers; responds to inquiries, complaints, and reconsiderations. Documents call in inquiry tracking system. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Receive escalated calls that cannot be clinically resolved by 1st level intervention. Researchers resolve and respond to provider clinical inquiries.
- Supports Fraud and Abuse program system oversight. Communicates any suspected fraud discovered by the contact center staff. Recommends a course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards.
- Serves as second-line contact for all internal pharmacy related issues. Functions as a clinical liaison between internal staff and pharmacy network participants. Ensures internal changes that may affect network services are reflected in the claims processing system.
- Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review. Works with appropriate individuals/vendors to facilitate compliance. Responds to and drafts correspondence to physicians regarding requests on Drug Formulary. Responds to telephone inquiries from physicians, other healthcare professionals and members regarding select drug information.
- Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization. Assures compliance with PerformRx policies and procedures regarding pharmacy protocol.
- Participates in various Pharmacy-related projects. Performs appropriate research, analysis and generates findings report. Submits recommendation to Manager for review and input. May assist in the implementation and/or coordination of project changes.
- Supports the MTM/DTM program through activities which may include the following: Performs medication therapy reviews to identify medication related problems, performs interactive consultations and makes recommendations/interventions for members and providers, appropriately documents all pharmacotherapy interventions, responds to questions and provides clarification for requests generated in regards to MTM/DTM programs.
- Has attended or attends MTM/DTM certificate training.
- Complies with URAC/CMS standards and regulation for DTMP.
- Performs other related duties and projects as assigned. Attends required training on an annual basis.
NOTE:-
- Current pharmacy license, Commonwealth of Pennsylvania preferred.
- Pharm D. preferred.
- 2 years pharmacy experience preferred.
- Previous experience in managed care environment preferred.
- MTM/DTM certificate training preferred.
Regards,
Riya Khem
Life Science Recruiter
Integrated Resources, Inc.
IT Life Sciences Allied Healthcare CRO
(Direct) 732-844-8721 | (W) 732-549-2030 x 311 | (F) 732-549-5549
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