Job Description

Job Title: Pharmacy Clinical Review Specialist, RxPartners
Job ID: 87965249
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Community Provider Svcs
Department: Bridgeville Pharmacy
Location: 500 Old Pond Rd, Bridgeville PA 15017

Description

Purpose:
Oversee administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests for Community Provider Services and their customers to ensure payment. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the quality review of requested prior authorizations.

Responsibilities:
  • Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
  • Perform peer reviews of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
  • Interface with other departments and identify medical documentation in support of prior authorization requests.
  • Participates in the monthly billing process and assist with collection of delinquent accounts.
  • Act as a conduit of information between the Pharmacy, operations and clinical and the facility staff.
  • Report and respond to escalate issues and concerns in a within twenty-four hours.
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.

Qualifications

  • HS diploma or equivalent required
  • 2 years of pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.
  • Experience in pharmacy claims process operating system required.
  • Excellent knowledge in retail pharmacy processes and LTC Pharmacy billing functions preferred.
  • Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management required Thorough knowledge in MS Office and PC skills required. 
  • Customer Service experience with communication via telephone, e-mail and face to face required.
  • Knowledge of electronic claims adjudication and resolution required
  • Experience with prioritizing and multitasking required

Licensure, Certifications, and Clearances:
Certified Pharmacy Technician preferred

  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

    Salary Range: $16.72 to $26.54 / hour

    Union Position: No

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