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Centene Corporation

Pharmacy Technician (Medicare Program Management) Rancho Cordova, CA

Centene Corporation - Rancho Cordova, CA

Job ID 1097501Date posted 05/08/2018Category Health Insurance OperationsOrganization Envolve PharmacySchedule Full-timeDescription: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 plansSubmits and maintains formulary change requests to Health Net’s pharmacy claims processorGenerates, maintains and reviews Formulary Status GridsUses reports to perform audits and quality checks on the current formulary status for accuracy and contract complianceAssists Clinical Pharmacist with formulary database maintenance and updates to company web sitePharmacy 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 findingsAnswers in-coming calls and responds appropriately to faxed correspondence from pharmaciesUpdates Access database with incoming phone calls, faxes and e-mailsPharmacy Services Center: Takes member inquiry calls for benefit questions including prior authorization requestsMaintains 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 inquiriesResearches 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 filesResearches and resolves issues using the appropriate reference materialAssists in pharmacy claims corrections projectsPerforms audits and quality checks on active prior authorizations claimsAssists with identifying and correcting eligibility and group issuesProcesses member claimsState Health programs Pharmacy Operations Liaison to internal and external departments for SHP pharmacyOperational issue resolution, including issues from Prior Auth, Appeals and Grievances, andMember/Provider ServicesPreparation and review of various operational reports and auditsSHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenanceMaintenance of prior authorization database filesMedi-Cal DMR processingAssist with SHP clinical projectsAssist with Medi-Cal prior authorizationsOversight and Audit SupportAssists in the implementation of regulatory changesParticipates in maintaining consistent processes/methods for development, implementation, communication and training on new/updated policies and proceduresParticipates 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 departmentsProvides 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 preferredLicense/Certification: Valid Pharmacy Technician LicenseCentene 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.

11 days 3 hours ago

Centene Corporation


Pharmacy Technician (Medicare Program Management) Rancho Cordova, CA 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