Pharmacy Analyst - 40 hrs/wk - Henry Ford Troy

General Summary

Responsible for handling of daily pharmacy duties such as drug claim adjudication issues, prior authorization, and pharmacy benefit inquiries from members/patients, physicians, pharmacies, and other internal and external individuals. Subject matter

expert in the resolution of pharmacy benefit coverage issues and coordinating prior authorization and exception processes.

Principle Duties And Responsibilities

Health Plan Based

• Process and research requests for prior authorizations and other requested exceptions.
• Perform quality assurance checks on claim adjudication for compliance/oversight.
• Troubleshoot and resolve drug claim issues for patients, physicians, pharmacies, and internal staff.
• Work with vendors such as pharmacies, other mail order facilities, claims processors, etc. to resolve issues and improve processes.
• Assist or Administer pharmacy benefit designs for contracted health plans and/or pharmacies (i.e. Health Alliance Plan/Pharmacy Advantage).
• Act as a resource for pharmacy benefit questions.
• Produce and maintain assigned databases, reports, logs, summaries, and other documents as needed.
• Perform additional related duties as assigned or necessary.
  
  

Pharmacy/Clinic Based

• Act as a central resource to manage and monitor prior authorization and its validity prior to fill and provide a reason if prior authorization is denied.
• Relays all communications to patients and providers regarding authorization outcome.
• Proactively renews prior authorization in timely manner to provide continuity of care.
• Proactively research and secure financial assistance for all patients.
• Interpret patient treatment plans and medical notes for purposes of facilitating authorization requests.
• Evaluate & communicate with nursing and physician staff any additional requirements or potential barriers to the treatment plan.
• Act as a resource to assist with education of new hires.
• Create and maintain patient/member information in applicable systems.
• Work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families.
• Perform additional related duties as assigned and necessary.
  
  

Education/Experience Required

 High school diploma or G.E.D. equivalent. Associates degree preferred.

 A minimum of one year of previous pharmacy experience required.

 State of Michigan Pharmacy Technician Licensure preferred.

 Strong understanding and knowledge of medical/clinical and pharmacy terminology.

 Working knowledge of personal computers, and business software such as Microsoft Office.

 Organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and job duties/responsibilities.

 Strong interpersonal communication skills and experience with interacting with customers.

Additional Information

• Organization: Community Care Services
• Department: Pharmacy-Utilization Mgmt
• Shift: Day Job
• Union Code: Not Applicable