Job Description

_ GENERAL SUMMARY:_

The Pharmacy Benefits Specialist is responsible for handling drug claim adjudication issues, prescription prior authorization, and pharmacy benefit inquiries from members/patients, physicians, pharmacies, and other internal and external individuals. Is a subject matter expert in the resolution of pharmacy benefit coverage issues and coordinating prior authorization and exception processes.

_ PRINCIPLE DUTIES AND RESPONSIBILITIES:_

• Performs benefits investigation, prescription prior authorization, and researches financial assistance needed to ensure patients have access to medications needed.
• Acts as a central resource to manage and monitor all medication related inquiries from providers/clinics.
• Interprets patient treatment plans and medical notes for purposes of facilitating patient care.
• Communicates in timely manner to patients and providers regarding authorization outcome.
• Evaluates any pharmacy related inquiries (i.e., financial barriers, therapy management related outcomes, non-adherence to therapy) and communicates with nursing, providers, social workers and physician staff any additional requirements or potential barriers to the treatment plan.
• Performs all necessary steps during order entry to ensure order gets to final verification. Ensures the process is completed quickly, accurately, and in accordance with patient’s needs while maintaining the highest customer service/quality of care.
• Performs online ordering of prescriptions submitted to pharmacies. May perform pharmacy technician duties (i.e., data entry, product dispensing, selling prescriptions on the POS and delivering prescriptions).
• Communicates directly with enrolled patients to ensure that they are supported throughout their therapy regimen and achieve their intended outcome.
  • This includes: Conducts outbound phone calls for patient support, adherence checks, and refill reminders.
  • Accepts inbound calls from patients and addressing patient needs.
  • Appropriately triages clinical questions to the appropriate clinician (pharmacist, nurse, or provider).
  • Obtains and documents medication history in appropriate software systems.
• Acts as a resource to assist with orientation and training of new hires.
• Creates and maintains patient/member information in applicable systems.
• Performs additional related duties as assigned.

Qualifications

_ EDUCATION/EXPERIENCE REQUIRED:_

• Requires a High school diploma or G.E.D. Associates degree preferred. Requires State of Michigan Pharmacy Technician License.
• Requires a minimum of two years of previous pharmacy technician experience.
• Previous experience as a specialty pharmacy technician preferred. Knowledge in the specialty disease states (Oncology, Autoimmune Disease, Neurology, Hepatology, other miscellaneous Specialty Diseases) preferred.
• Experience working with multidisciplinary team. Knowledge of benefits investigation, prior authorization support, and patient financial assistance work preferred.
• Requires a strong understanding and knowledge of medical/clinical and pharmacy terminology. Proficiency in standard workplace software (MS office) required.
• EMR systems (Epic or Cerner), dispensing systems (McKesson Enterprise, QS1, or RX30) and specialty pharmacy patient management programs (Asembia-1, Therigy, or Dromos PTM) experience is preferred.
• Requires organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and job duties/responsibilities.
• Must be reliable and willing to assume additional responsibilities.