Overview
This is a short-term assignment.
What you can expect!
Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!
Under the direction of the Medication Management Pharmacy Operations Supervisor, the Pharmacy Medication Management Specialist is responsible for the preparation of member medication reconciliations, comprehensive medication reviews (CMRs), targeted medication reviews (TMRs) and their respective written notifications to the provider/member for clinical review. The Pharmacy Medication Management Specialist must be able to utilize all policies and resources to answer questions and direct Providers/Members appropriately in order to resolve their concerns, accept and make phone calls concerning all facets of medication management and schedule appointments appropriately. The Pharmacy Medication Management Specialist will need to demonstrate the ability to listen to Provider/Member concerns and questions and be able to accurately document medication/allergy history, as well as communicate health plan processes in a clear and knowledgeable manner. The Pharmacy Medication Management Specialist will also be responsible for the technical review of the prescription drug prior authorization and notifying the provider of the clinical decision.
Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Key Responsibilities
Technical review of authorizations (drug) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation.
Decision prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
Preparation of medication reconciliation reviews, CMRs and TMRs that includes reviewing chart notes, electronic medical records, and/or relevant clinical information to submit for pharmacist clinical review/recommendation.
Provide excellent customer service on all inbound and outbound calls. This includes but is not limited to the following: demonstrating a high level of patience and respect with every call subject, avoiding distractions to ensure each call subject is assisted promptly and appropriately ensuring a positive provider/member experience.
Communicate with providers (doctor and pharmacy) and members on issues related to the medication reconciliation, or respective policies and procedures.
Access electronic medical records (EMRs) claims systems (PBM and medical claims), and other information systems to thoroughly document medication reconciliation reviews, CMRs, TMRs, and prior authorizations in relevant program systems.
Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
Ensure all company’s goals (including, but not limited to the 5 Strategic Priorities: Quality of Care and Service, Access to Care, Practice Transformation, Human Development and Technology and Data Analytics).
Communicate with providers (doctor and pharmacy) on issues related to the IEHP formulary, non-formulary criteria, or respective policies and procedures.
Interface with IEHP’s pharmacy benefit management (PBM) company, when necessary, in regard to adjudication and medication processing issues.
Assist in expedited review of discharge related orders or requests and coordination with specialty pharmacy providers (disease therapy management program), and internally with Utilization Management, Behavioral Health, or Care Management departments.
Assist Clinical Pharmacist in review of Member’s medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments.
Actively participate in internal quality improvement process enhancements, LEAN projects, and managing for daily improvement (MDI).
Participate in various pharmacy projects to meet the standards of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Projects included, but not limited to, pharmacy utilization management review, provider and pharmacy outreach, formulary alternative conversion and discharge medication transition.
Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues.
Assist with direction on the IEHP Provider webpage as needed.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
Qualifications
Education & Requirements
- One (1) or more years of experience as a pharmacy technician in a pharmacy required
- Experience in a pharmacy benefit management setting preferred
- High School Diploma or GED required
- Associate’s degree or Bachelor’s degree from an accredited institution preferred
- Possession of an active, unrestricted, and unencumbered Pharmacy Technician license issued by the California State Board of Pharmacy required
Key Qualifications
- Knowledge in pharmaceutical terminology is required
- Microsoft Office (Microsoft Excel skills preferred)
- Excellent organizational, written, and verbal communication required
- Project management skills preferred
- Good interpersonal skills. Excellent critical thinking skills
- Typing speed of 40 corrected words per minute (CWPM) required
- Highly motivated and self-starter. Detail-oriented
- Display the ability to adapt and perform duties efficiently whenever unexpected changes arise
- Works well in a fast-paced environment
Start your journey towards a thriving future with IEHP and apply TODAY!
Work Model Location
Telecommute (All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)
Schedule may adjust based on business need which may include evenings, holidays, and weekends
Pay Range
USD $27.43 - USD $35.66 /Hr.