Supports comprehensive coordination of Medicaid and/or Medicare pharmacy services including intake and processing of pharmacy authorization requests. Promotes and supports quality effectiveness of healthcare and Pharmacy Services. Evaluates, authorizes approval, and communicates decisions for pharmacy requests according to clinical guidelines.
- High volume call center and production unit
- Evaluates and authorizes approval of pharmacy requests received by telephone, facsimile, and/or other means using client clinical criteria. Determines appropriateness for medications
- Communicates decision to physicians, physician's office staff, medical management staff, members, and/or pharmacists
- May perform clinical research to support request
- Utilizes various proprietary systems to build, research, process and enter requests
- Performs non-medical research including eligibility verification, COB, and benefits verification
- Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
- Escalates requests to Pharmacist when request requires extensive clinical review or denial.
- Promotes communication, both internally and externally, to enhance effectiveness of medication therapy management services
- Protects the confidentiality of member information and adheres to company policies regarding confidentiality
- May communicate with Aetna Case Managers and Health Plan staff
- Process requests in compliance with various laws and CMS regulations and company policies and procedures
- Sedentary work involving significant periods of sitting, talking, hearing, and keying
- Work requires visual acuity to perform close inspection of written and computer-generated documents as well as dual PC monitors
- National Pharmacy Technician certification and Arizona State License, current and in good standing, are required
- Experience in retail, hospital, facility or call center is preferred.
- Proficiency in computerized pharmacy systems and software applications
- Excellent verbal and written communication skills
- Experience with Windows-based software applications
High School diploma, G.E.D. or equivalent experience
Percent of Travel Required
Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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