Tecnico(a) de Servicios de Farmacia
Regular
Non-Exempt
GENERAL DESCRIPTION:
Receive and follow-up requests by phone or fax, monitor, evaluate, and channel service/follow-up requests received for all the company business lines. Evaluates the guides and compliance criteria to authorize services of determinations and organizational appeals. Makes data entry related to the request processing in the various existing electronic applications.
ESSENTIAL FUNCTIONS:
Receives medication-related requests from medical component and pharmacy benefit components for coverage determinations, organizational determinations, and appeals via electronic channels, then channels them appropriately for both lines of business.
Analyzes and verifies requests, including medical orders, to identify the type of service requested such as valid prescription, eligibility, benefit coverage, limitations and exclusion, and identification of a provider and channels them to the corresponding agents for the appropriate setting according to the service required.
Performs data entry of events in the corresponding system and documents the demographic and clinical information (medical order) pertinent to the patient requesting the service.
Channels requests that require authorization based on medical necessity to the pharmacy technician or corresponding person for review and determination.
Answers the calls received in the department, directs them to the corresponding programs and ensures compliance with the privacy policy while handling information.
Addresses pre-authorization status inquiries from authorized individuals, ensuring adherence to Health Insurance Portability and Accountability (HIPAA) regulations.
Ensures the proper distribution and channeling of incorrect cases referred to a department.
Receives and manages the Determination case file request with the Pharmacy Benefit Management (PBM).
Evaluates, organizes, and distributes Pharmacy Commercial Appeals requests following the established requirements.
Provides support to clinical staff in administrative tasks, such as making calls to providers and patients, photocopying, scanning, and filing documents, among others.
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 and Experience:
Associate's Degree in Medical Billing or Pharmacy Technician is preferred. At least six (6) months to one (1) year of experience as a pharmacy technician or in a similar position, or one (1) to three (3) years of experience instead of.
OR
Education and Experience:
At least sixty to sixty-four (60-64) college credits. At least six (6) months to one (1) year of experience as a pharmacy technician or in a similar position, or one (1) to three (3) years of experience instead of.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses:
Pharmacy Technician License and Registration is preferred. Other: Knowledge of Medical Terminology, CPT, and ICD-10 Codes.
Languages:
Spanish – Basic
(comprehensive, writing and verbal)
English – Basic
(comprehensive, writing and verbal)
"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento
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