This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects. This position must ensure performance is in compliance with organizational or departmental goals and in compliance with regulatory agencies. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs and based on clinical criteria.
Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues.
Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design.
Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination.
Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied
Process complaints, appeals, grievances, executive inquiries and compliance related issues.
Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary
Provide recommendations to increase efficiency, accuracy and productivity in the department.
Process ad hoc request for information or reports from stakeholders.
Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows.
Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program.
Provide support to various clinical programs within the pharmacy department.
Requires knowledge of popular brand and generic drug names.
Requires knowledge of third party prescription program claim adjudication.
Requires working knowledge of managed care principles.
Requires knowledge of common medical terminology.
Requires understanding of National Drug Code (NDC).
Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation
Additional Skills and Abilities:
Requires the ability to utilize a personal computer and applicable software.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.
Proven ability to exercise sound judgment and strong problem solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information.
Requires a High School diploma or GED
Requires National Pharmacy Technician Certification (PTCB or ExCPT)
Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration
Prefers minimum of two (2) years’ experience in third party prescription program claim adjudication.
Requires minimum of two (2) years’ experience as a Pharmacy technician.
Requires National Pharmacy Technician Certification (PTCB or ExCPT).
In lieu of the Pharmacy Tech Certification a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required.
Internal Number: 2019-1090
About Horizon Blue Cross Blue Shield of New Jersey
At Horizon Blue Cross Blue Shield of New Jersey, the collaboration between diverse professionals is one reason people are making NJ's largest health insurer their favorite place to work. With more than 3.8 million members, our goal is to provide individuals and employers in New Jersey with convenient access to quality, affordable health care.