Job title: Pharmacy Technician, AH Employee Health Plan
Company: Adventist Health
Job description: Job Description:Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus – a rejuvenating place for associates systemwide to collaborate, innovate and connect.Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.Job Summary:Supports health plan programs for managing pharmaceutical spend. Works with various health plan departments, including but not limited to care management, utilization management, and claims examination staff. Creates and/or reviews reports from the pharmacy benefit manager portal. Reviews pharmacy ranking reports. Summarizes pharmacy use by channel (in-house, community partner, mail-order pharmacies). Creates utilization management cases within care management software and assigns to appropriate reviewer. Runs pharmacy profile reports and uploads them into care management software. Acts as a subject matter expert on the employee pharmacy benefit, and is able to communicate with members regarding their benefit. Assists with analytics review of claims data from varied sources relative to potential patient needs and program development. Follows all compliance policies and procedures, applicable laws and regulation adapted by AH including: Fraud Awareness, HIPAA, use of organizational approved web sites.Job Requirements:Education and Work Experience:
- High School Education/GED or equivalent: Preferred
- Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred
Licenses/Certifications:
- State Pharmacy Techncian license: Required in CA and OR
- Pharmaceutical Technician Board certification: Preferred
Facility Specific License/Certifications:
- State Pharmacy Technician (PTC): Required
Essential Functions:
- Actively monitors quarterly fraud waste and abuse reports. Creates a process to track identified members over time. Reports to clinical pharmacist members meeting identified criteria for care management referral. Reviews first time specialty fill reports. Researches each claim to ensure a clinical prior authorization was performed for each fill. Identifies members for redirection to a more appropriate site of care when necessary. Maintains quarterly metrics and be able to produce reports of metric trend.
- Calculates accurate HCPCS Code quantities to ensure correct quantities are being authorized. Runs pharmacy profile reports to look for previous treatments utilized. Helps redirect patients to most appropriate site of care for the medication being requested, optimizing 340B opportunities when applicable. Works with clinical pharmacist and claims examiners to create a streamlined process for review of all claims for unclassified drugs. Works with eligibility and health plan data departments to troubleshoot eligibility related pharmacy issues.
- Creates care management shells within care management software when the referral source is pharmacy data. Assigns case to appropriate care management staff. Works with the customer service pharmacy advocate to triage inquiries regarding the pharmacy benefit. Refers clinical questions to the health plan clinical pharmacist. Accurately documents interactions. Participates in all PBM calls and meetings.
- Performs non-clinical aspects of pharmacy benefit management. Tracks and maintains pharmacy utilization metric reports. Functions as a liaison with customer service. Collaborates with health plan communications department to create pharmacy benefit communications.
- Runs utilization reports from pharmacy and medical benefit software. Critically reviews reports to identify trends. Reports trends and outliers to clinical pharmacist and/or medical director.
- Performs other job-related duties as assigned.
Organizational Requirements:Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.About Us: Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God’s love by inspiring health, wholeness and hope.
Expected salary:
Location: USA
Job date: Sat, 14 Sep 2024 06:35:02 GMT
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