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Centene Corporation

Pharmacy Technician Medicare Program Management Oversight and Audit Support CA-Rancho Cordova

Centene Corporation - Rancho Cordova, CA

Pharmacy Technician Medicare Program Management Oversight and Audit Support CA-Rancho Cordova

in

Rancho Cordova

California

Description:

Position Purpose: The Pharmacy Technician may perform duties in one or more of the following areas: Formulary Management, Pharmacy Audit and Recovery, Pharmacy Service Center or Prior Authorization, Medicare Part D Operations and State Health Programs Pharmacy Operations.

Formulary Management:

Reviews and processes formulary change requests from Health Net plans

Submits and maintains formulary change requests to Health Net s pharmacy claims processor

Generates, maintains and reviews Formulary Status Grids

Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance

Assists Clinical Pharmacist with formulary database maintenance and updates to company web site

Pharmacy Audit and Recovery:

Performs a variety of assignments required for pharmacy audit and recovery functions.

Reviews paid claims for quantity and/or billing discrepancies. Corresponds with pharmacies as needed to communicate review finding.

Faxes inquiries to pharmacies related to review findings

Answers in-coming calls and responds appropriately to faxed correspondence from pharmacies

Updates Access database with incoming phone calls, faxes and e-mails

Pharmacy Services Center:

Takes member inquiry calls for benefit questions including prior authorization requests

Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position.

Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request.

Process member submitted claims.

Prior Authorization:

Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim.

Assign, enter and document prior authorizations into appropriate claims processing system.

Answer phone calls for prior authorization inquiries

Researches and resolves issues using the appropriate reference material.

Responsible for knowing and interpreting pharmacy and medical benefits.

Medicare Part D Operations

Reviews and processes PDE files

Researches and resolves issues using the appropriate reference material

Assists in pharmacy claims corrections projects

Performs audits and quality checks on active prior authorizations claims

Assists with identifying and correcting eligibility and group issues

Processes member claims

State Health programs Pharmacy Operations

Liaison to internal and external departments for SHP pharmacy

Operational issue resolution, including issues from Prior Auth, Appeals and Grievances, and

Member/Provider Services

Preparation and review of various operational reports and audits

SHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenance

Maintenance of prior authorization database files

Medi-Cal DMR processing

Assist with SHP clinical projects

Assist with Medi-Cal prior authorizations

Oversight and Audit Support

Assists in the implementation of regulatory changes

Participates in maintaining consistent processes/methods for development, implementation, communication and training on new/updated policies and procedures

Participates with Business Units/departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into P&Ps that span multiple departments

Provides support and monitoring to ensure compliance of First Tier, Downstream and Related Entities (FDRs)

Assists with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)

Qualifications:

Using established company guidelines, the Pharmacy Technician reviews requests made by physicians, medical groups, pharmacies and members for the use of prescription drugs and pharmacy benefits. The technician researches and resolves questions, problems or issues. May consult with Clinical Pharmacists or Regional Medical Director on related issues.

Education/Experience: High School diploma or GED required. Two years Pharmacy Technician experience. Customer Service/retail experience preferred

License/Certification: Valid Pharmacy Technician License

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Job:

Health Insurance Operations

Organization:

Envolve Pharmacy

Location:

California-Rancho Cordova

Requisition ID:

1079079

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12 days 14 hours ago

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Pharmacy Technician Medicare Program Management Oversight and Audit Support CA-Rancho Cordova Centene Corporation - Rancho Cordova, CA, United States

   

Location: Rancho Cordova, CA

Company Profile:
Founded as a single health plan in 1984, Centene Corporation (Centene) has established itself as a national leader in the healthcare services field. Today, through a comprehensive portfolio of innovative solutions, we remain deeply committed to delivering results for our stakeholders: state governments, members, providers, uninsured individuals and families, and other healthcare and commercial organizations