Presbyterian is seeking a Clinical Pharmacy Review Specialist
The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.
This position is responsible for providing clinical support for the Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances.
This is a Full Time position - Exempt: NoJob is based at Rev Hugh Cooper Admin CenterWork hours: Days
Ideal Candidate:
GED or High School diplomaCertified Pharmacy Technician-PTCBExperience with pharmacy benefits management, health insurance and or prescription benefitsRetail Pharmacy experience Qualifications GED or High School diploma is required.Certified Pharmacy Technician-PTCB is requiredExperience with pharmacy benefits management, health insurance and or prescription benefits is preferredRetail Pharmacy experience preferredManaged care customer service experience preferredDrug Information skillsExperience with Medicare Part D insurance and Medicaid programs Responsibilities Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocolsCompletes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasksAssign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs.Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiriesEffective oral and written communication skills.Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.May perform activities that require evaluation or interpretation of information related to drug administration and treatments.Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy ManagementAbility to meet established deadlines timely, accurately and with a sense of urgencyResponsible for knowing and interpreting pharmacy and medical benefits.Knowledge of Medical terminology and HIPAA regulationsPerform other duties as assigned. BenefitsAbout Presbyterian Healthcare Services
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.
The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges, webinars, and screenings - with opportunities to earn gift to earn gift cards and other incentives.
As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships. Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
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