Summary/Position Objectives:
The UM pharmacy benefit coordinator is responsible for supporting the pharmacy utilization management process. This includes utilization management intake for electronic and telephonic requests and clinical outreach services to our members, their pharmacies and their healthcare providers.
In addition, the Pharmacy Benefit Coordinator performs a variety of routine to moderately complex administrative and pharmacy-related tasks that support the Pharmacy Management team within the department. The Pharmacy Management team is responsible for the management of the pharmacy benefit for Maryland Physicians Care, a Medicaid MCO in collaboration with the pharmacy benefit management (PBM) vendor and other internal departments. This position will ensure a high level of quality and accuracy in the pharmacy benefits administered while also delivering excellent member services. This position will also support the organization’s utilization review, quality improvement, provider relations, and population health initiatives.
What You’ll Do:
· Perform intake on Prior Authorization, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness and efficiency standards.
· Communicate UM decision notifications professionally with providers and clinic groups.
· Work collaboratively with UM pharmacists to ensure state and federal regulatory compliance with UM management.
· Supports the accurate implementation and coding of pharmacy benefit, formulary, and program changes, including review of PBM testing scenarios.
· Reviews pharmacy services recommended for denial. Of those recommendations, investigates and reviews data and information retrieved from plan providers.
· Assists in the management of members by collecting pertinent information from plan providers and other pharmacy data systems.
· Assists in various pharmacy, utilization review/management, quality improvement, provider relations, and population health initiatives.
· Serves as a pharmacy liaison and resource person to plan pharmacies and members.
· Identifies issues and problem areas and participates in the development of solutions.
Requirements
Knowledge and Skills:
- Ability to identify, communicate findings, and resolve member, provider, process and/or system issues, communicating recommendations verbally and in writing.
- Business writing and presentation skills, including the ability to write clear, concise reports.
- Meticulous attention to detail, including but not limited to interpreting and understanding benefits/codes.
- Demonstrates skills in problem-solving, decision-making, conflict resolution, and the ability to work independently and in a team environment.
- Familiarity with government relations with the ability to operationalize and understand how various aspects of regulation are interdependent and related.
- Excellent organization, time management, project management skills, multi-taking abilities, diplomacy and professionalism plus a strong sense of urgency leading to the timely completion of all projects and assignments.
Education and Work Experience:
- Current Maryland State Pharmacy Technician licensure, including certification from a nationally recognized Pharmacy Technician Certification Board.
- High School diploma or equivalent.
- Two (2) years of experience as a pharmacy technician working in a managed care, insurance, PBM, or equivalent environment.
- Experience supporting utilization management/prior authorization processes.
- Experience in Medicaid and/or Medicare, with a thorough understanding of prescription benefit management programs and practices.
