Evaluates and authorizes approval of prior authorization pharmacy requests from prescribers received by telephone and/or facsimile using client clinical criteria.
Determines appropriateness for medications. Communicates decision to physicians, physician`s office staff, medical management staff and/or pharmacists.
Researches, resolves and documents prior authorization outcomes in pharmacy system.
Communicates selected prior authorization criteria, pharmacy benefit coverage and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.
Escalates requests to Pharmacist when request requires extensive clinical review or denial.
Researches, resolves and documents physician or client inquiries and grievances and provides verbal or written results to client, prescriber, provider and/or management.
Performs other duties as required.
General Job Information
United States of America
United States of America (Non-Exempt)
Recruiting Start Date
Date Requisition Created
GED (Required), High School (Required)
License and Certifications
CPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements
License and Certifications
Other Job Requirements
CPT: Certification/licensure in accordance with state requirements. In the states of Florida, Rhode Island and Michigan, license registration with the Board of Pharmacy is required without exception.
PTCB: Certification or the ability to obtain PTCB Certification within one year of hire. Employees in states which require a Pharmacy Technician certification/registration exam may substitute state certification/registration for the PTCB.
Specialty or retail pharmacy industry experience, previous reimbursement experience, and/or working in a health plan/health care setting.
In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques, medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-9, CMS 1500, etc.).
Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.
Excellent written and verbal communication skills.
Ability to follow clinical criteria and instructions to approve prior authorization requests.
Minimum of 6 months dispensing or retail experience required, or equivalent internal training will be substituted.
Ability to identify and trouble-shoot problematic issues.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
Magellan Health Services