General Purpose of Job:

Position responsible for the daily workflow and operations relating to the delivery of pharmacy services to PHP members and providers. This position processes pharmacy prior authorization requests and handling incoming phone calls to the department.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Participates in daily processing of medication prior authorization (PA) requests, to include compiling necessary information required for the PHP pharmacist or medical director for benefit determination review, and drafting PA outcome and notification letters
• Respond to incoming telephone, fax or written requests for services, inquiries from members or providers regarding pharmacy benefit coverage and interpretation.
• Make outbound telephone calls and faxes to gather additional needed information for resolving inquiries, authorizations and other issues.
• Processes Benefit Determinations within DOL, MDCH and URAC timelines.
• Research and resolve issues relating to claims payment and authorization documentation.
• Act as resource to members and providers regarding pharmacy benefits, to include utilizing appropriate tools for verifying eligibility, coverage, and policy information.
• Enter required notification information, benefit determination results, and other documentation into internal medical management system (Facets) within pre-determined benchmarks for accuracy and timeliness according to established procedures.