Job Title: Pharmacy Technician Job Description The Pharmacy Technician supports multiple pharmacy operations areas, including formulary management, pharmacy audit and recovery, pharmacy service center, Medicare Part D and Part B, appeals, state health programs pharmacy operations, prior authorization, and oversight and audit support. Using established guidelines, this role reviews requests from physicians, pharmacies, medical groups, and members for prescription drugs and pharmacy benefits, researches and resolves issues, and collaborates closely with clinical pharmacists and other healthcare professionals to ensure accurate, compliant, and timely processing of pharmacy-related requests.
Responsibilities Review and process formulary change requests from health plans and submit updates to the pharmacy claims processor. Generate, maintain, and review formulary status grids to ensure accuracy and contract compliance. Use reports to perform audits and quality checks on current formulary status. Assist clinical pharmacists with formulary database maintenance and updates to the company website.
Perform a variety of assignments related to pharmacy audit and recovery functions. Review paid claims for quantity and billing discrepancies and communicate findings to pharmacies. Send fax inquiries to pharmacies regarding audit findings and respond to faxed correspondence. Answer incoming calls from pharmacies and respond appropriately to questions and concerns. Update databases, including Access, with information from phone calls, faxes, and emails.
Take member inquiry calls regarding pharmacy benefits, including prior authorization requests. Maintain expert knowledge of Medicare pharmacy benefits and formularies, including relevant regulations. Educate members on their specific pharmacy benefits and explain options such as prior authorization requests. Process member-submitted pharmacy claims accurately and efficiently. Review requests from physicians and pharmacies for non-formulary drugs, drugs requiring prior authorization, and prescriptions that exceed quantity or cost limits.
Assign, enter, and document prior authorizations into the appropriate claims processing system. Answer phone calls related to prior authorization inquiries and provide clear information. Research and resolve issues using appropriate reference materials and tools. Understand and interpret pharmacy and medical benefits to support accurate decision-making. Review and process Medicare Part D event (PDE) files.
Assist with pharmacy claims correction projects and perform audits and quality checks on active prior authorization claims. Help identify and correct eligibility and group issues and process member claims as needed. Serve as a liaison to internal and external departments for state health program pharmacy operations. Resolve operational issues related to prior authorization, appeals and grievances, and member or provider services.
Prepare and review various operational reports and audits for state health programs. Perform formulary management functions for state health programs, including quarterly formulary updates to the website, databases, and benefit maintenance. Maintain prior authorization database files and process Medi-Cal direct member reimbursement (DMR) requests. Assist with state health program clinical projects and Medi-Cal prior authorizations.
Assist in the implementation of regulatory changes affecting pharmacy operations. Participate in developing, implementing, communicating, and training on new or updated policies and procedures. Collaborate with business units and departments to ensure end-to-end process connectivity and effective handoffs across multiple departments. Provide support and monitoring to help ensure compliance of first tier, downstream, and related entities.
Assist with department preparation for internal and external audits, including building case files, universes, and evidence of compliance. Identify the validity of appeals