Overview:
What you can expect!
Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!
Under the direction of the Supervisor, Pharmacy Utilization Management (RxUM), the Pharmacy Technician - Utilization Management (RxUM) is responsible for the technical/clinical review of the utilization management authorization request with a medication component.
Applicable to Bilingual job code only - This is a Bilingual (English/Spanish) position. The Team Member in this role must take a language proficiency assessment and must receive a passing score.
Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
Additional Benefits:
Perks
IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.
- Competitive salary
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
Key Responsibilities:
- Input, review and decision Medicare Part B and Medi-Cal requests for J codes, S code, Q codes, B codes and other medical benefits drugs/supplies
- Review Requests based on UM logic and criteria including but not limited to LCD, NCD, UM manual, MCG, MDX and other establish criteria when applicable
- Technical/Clinical review of authorizations (drug and utilization management) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation
- Decision prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance
- Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met
- Ensure all company’s goals (including, but not limited to the 6 Strategic Priorities: Member Experience, Network, Team Member, Operational Excellence, Technology, and Financial Stewardship)
- Communicate with providers (doctor and pharmacy) on issues related to the IEHP RxUM policies and procedures
- Interface with IEHP’s pharmacy benefit management (PBM) company, when necessary, in regard to adjudication and medication processing issues
- Assist in expedited review of discharge related orders or requests and coordination with specialty pharmacy providers (disease therapy management program), and internally with Utilization Management, Behavioral Health, or Care Management departments
- Assist Clinical Pharmacist in review of Member’s medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments
- Actively participate in internal quality improvement process enhancements, LEAN projects, and managing for daily improvement (MDI)
- Participate in various pharmacy projects to meet the standards of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Projects included, but not limited to, pharmacy utilization management review, provider and pharmacy outreach, formulary alternative conversion and discharge medication transition
- Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues
- Any other duties as required to ensure Health Plan operations are successful
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance
Qualifications:
Education & Requirements
- One (1) or more years of experience as a pharmacy technician in a pharmacy required
- Experience in a pharmacy benefit management setting preferred
- High school diploma or GED required
- Possession of an active, unrestricted, and unencumbered Pharmacy Technician license issued by the California State Board of Pharmacy required
- Applicable to Bilingual job code only - Bilingual (English/Spanish) - written and verbal skills required
Key Qualifications
- Knowledge in pharmaceutical terminology is required
- Excellent organizational, written, and verbal communication required
- Typing speed of 40 corrected words per minute (CWPM) required
- Microsoft Office (Microsoft Excel skills preferred)
- Good interpersonal skills
- Excellent critical thinking skills
- Display the ability to adapt and perform duties efficiently whenever unexpected changes arise
- Highly motivated and a self-starter
- Detail-oriented
- Works well in a fast-paced environment
Start your journey towards a thriving future with IEHP and apply TODAY!
Work Model Location:
Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)
Schedule may adjust based on business need which may include evenings, holidays, and weekends
Pay Range:
USD $27.43 - USD $35.66 /Hr.
