Please send resumes to: email@example.com
Phone Number: 831.663.4000
Position: Pharmacy Technician
Location: Monterey, CA
Reports to: Medical Director
Schedule: Monday through Friday, 8:00am to 5:00pm
Purpose of Position
The Pharmacy Technician will assist the Pharmacist and Chief Medical Officer (CMO) with activities related to provision of the Part D benefit. Activities include PBM oversight, customer service, member and provider outreach, and additional support activities as determined by the pharmacist or CMO.
• Oversight of delegated PBM; review of daily rejected claims and member call logs, in depth monthly review of approved and rejected claims, monthly review of posted/published formulary, monthly review of redeterminations and Part D grievances
• Review and monitoring of claim denials by PBM
• Review Prescription Drug Event (PDE) data to:
• Identify errors with member eligibility, Low Income Subsidy Cost Sharing, as well as processing Institutional, ESRD and Hospice prescription drug claims
• Monitor and report prescription drug metrics, to include but not limited to, review of B versus D drugs, appropriate Copay and Deductible calculation and corrective actions for informational and rejected PDE claims
• Monitor and ensure correction of FIR (Troop Balance Transfer) errors within 15 days of receipt
• Complete Coverage Gap Discount discrepancy reports, as required
• Coordinate with pharmacy team and Pharmacy Benefit Manager to monitor members enrolled in the Medication Therapy Management (MTM) and ensure timely reporting to CMS
• Review Part D HEIDIS metrics to identify members for outreach and coordinate with PBM, Medical Management and network providers to close gaps
• Responsible for follow-up with members and providers to resolve issues related to medication adherence
• Assist Plan Compliance officer to investigate member complaints and CMS notification of Pharmacy/Provider fraud. Assist Compliance Officer in the review of the company’s Fraud Waste and Abuse (FWA) program
• Risk Identification - identify new members with conditions that are not showing up on claims
• Assist with resolution of pharmacy-related member issues to include outbound customer service calls to members and delegated partners
• Gathering information, documentation, and communication for Part C medication-related organizational determinations and prior authorizations.
• Perform activities to support Part D functions of the health plan as delegated by the pharmacist or CMO 2
• Perform data entry into multiple systems and databases, including authorization and disease management information
• Develop excellent professional relationships with our provider and insurance company partners
• Demonstrate understanding and accurate interpretation to support compliance with regulatory standards, e.g. Medicare Advantage and HIPAA
• Prioritize and plan work for completion in a timely manner, coordinating with others as needed and meeting deadlines set on all phases of work
• Demonstrate the ability to adapt to changes in the workload and responsibilities
• Perform other activities and functions as required
• Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.
• Integrity: Consistently honors commitments and takes responsibility for actions and words.
• Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
• Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.
• Active pharmacy technician license in California.
• Two years of pharmacy technician experience
• One year of a retail pharmacy experience
• Must possess a high degree of professionalism
• Customer service orientation
• Strong work ethic
• Excellent communication skills (written and verbal), and the ability to maintain a positive attitude when dealing with both internal and external customers
• Basic understanding and interpretation of medical terminology and diagnosis codes as well as therapeutic drug classes is required
• Strong problem-solving skills and the ability to work independently
• Attention to details in obtaining complete and accurate information
• Ability to key data accurately and rapidly
• Working knowledge of Excel and Access, or similar programs and databases
• Must be able to problem solve
• Must be able to meet established deadlines
• Health plan experience
• Pharmacy technician certification
• Regulatory compliance experience
• Quality Assurance experience
Mission Valley ROP does not provide resume or application assistance. The job process is the applicants’ responsibility.