- Determines appropriateness for medications. Communicates decision to physicians, physicians 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, physicians 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.
Other Job Requirements
ResponsibilitiesMust have an active pharmacy technician licensure or registration in accordance with state requirements.
If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT).
In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT).
Active Pharmacist license supersedes requirement for CPT and/or PTCB.
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.
General Job Information
Work Experience - RequiredPharmacy
Work Experience - Preferred
Education - RequiredGED, High School
Education - Preferred
License and Certifications - RequiredCPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.