Técnico(a) De Farmacia En Revisión De Medicamentos Y Cubierta Médica
Regular
Non-Exempt
GENERAL DESCRIPTION:
Receives and attends calls from clients (insured parties, medical providers, specialized pharmacies) related to the medication management process. This involves making pre-authorizations according to established guidelines and procedures, validating medication coverage (among other things), and documenting in the system the service provided for the two company business lines. Participates with the Pharmacy Supervisor in tasks related to the validation of drug coverage, the search for clinical information to determine the substitution of a drug, the search for records of catastrophic patients, and the preparation of cases to determine if a medicine is covered or not within the medical coverage, among others, for the company's business lines.
ESSENTIAL FUNCTIONS:
•Participates in the resolution of cases (complaints or appeals) presented by agencies such as the Office of the Patient Advocate (OPP), Insurance Commissioner's Office, Legal Offices, among others.
- Participates in the audit process carried out by regulatory entities such as Puerto Rico Health Insurance Administration (ASES), the Centers for Medicare & Medicaid Services (CMS), among others.
- Guarantees that the patient can obtain prescribed medications according to clinical and administrative criteria established by the department.
- Channels requests from specialty pharmacy providers, physicians, and patients related to medication reimbursement under the medical coverage component.
- Receives calls and faxes related to the pre-authorization process under the medical coverage component for all business lines.
- Assigns codes in electronic pharmacy systems and company programs to allow billing by providers and physicians.
- Documents each request and actions taken in the corresponding systems.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education: Associate’s Degree in Pharmacy Technician. At least one (1) year of experience in pharmacy areas, health insurance plans, Pharmacy Benefit Management (PBM), and/or specialty pharmacy.
"Proven experience may be replaced by previously established requirements."
Certifications/Licenses: A valid Pharmacy Technician License and Registration is required.
Other: Knowledge of ICD-10 clinical criteria and/or HCPCS procedure codes.
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Basic (comprehensive, writing and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
