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Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
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Position Summary
Supports comprehensive coordination of Medicaid and/or Medicare pharmacy services including intake and processing of pharmacy authorization requests.
Promotes and supports quality effectiveness of healthcare and Pharmacy Services.
Evaluates, authorizes approval, and communicates decisions for pharmacy requests according to clinical guidelines.
Evaluates and authorizes approval of pharmacy requests received by telephone, facsimile, and/or other means using client clinical criteria.
Determines appropriateness for medications. Communicates decision to physicians, physician’s office staff, medical management staff, members, and/or pharmacists.
Will perform clinical research to support request.
Performs non-medical research including eligibility verification, COB, and benefits verification.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Process requests in compliance with various laws and CMS regulations and company policies and procedures.
May communicate with Aetna Case Managers, Health Plan Staff, External Pharmacies and Health Care Providers.
Promotes communication, both internally and externally, to enhance effectiveness of medication therapy management services.
Sedentary work involving significant periods of sitting, talking, hearing, and keying.
Escalates requests to Pharmacist when request requires extensive clinical review or denial.
Required Qualifications
National Pharmacy Technician certification and Home State License, current and in good standing, are required.
Proficiency in computerized pharmacy systems and software applications.
Excellent verbal and written communication skills.
Experience with Windows-based software applications.
Utilizes various proprietary systems to build, research, process and enter requests.
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
Preferred Qualifications
High volume call center and production unit.
Experience in retail, hospital, facility or call center is preferred.