Pharmacy Technician III

Central Coast Salary Range: $58,647 - $82,105 Annually

Job Summary

Under the direction and supervision of the Pharmacy Services Clinical Manager the Technician III position will utilize specialized pharmacy knowledge and expertise to assist the pharmacy department with all operational duties for Medi-Cal and Medicare Line of Business. The technician will work in pharmacy defined areas including:

1.  Utilization Management

2. Compliance Oversight

3. Drug Utilization Review

4. Pharmacy Benefit Manager (PBM) Oversight

5. Call Center Support.

6. Other Duties

Duties and Responsibilities

1.    Utilization Management 
•    Intake Medi-Cal and Medicare requests for J codes, Q codes, and other medical benefit drugs/supplies. 
•    Track and triage prior authorization requests submitted from providers .
•    Monitor prior authorization system to ensure turnaround times are met and contact provider for additional information to facilitate coverage determinations.
•    Enter and document coverage determination for prior authorization decisions rendered by a pharmacist.
•    Notify physicians, providers, and members of coverage determination request decisions.
•    Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.
•    Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/consultation by a pharmacist.
•    Perform utilization management and daily operational activities such as reporting and monitoring to assist pharmacy team across all lines of business as needed.
•    Support the pharmacists with quality and STARS related measures, including outreach to members, providers, and pharmacies.

2.    Compliance Oversight
•    Develop, maintain, and monitor Policies and Procedures (P&Ps), Compliance Program, and key performance indicators
•    Stay informed about the latest developments in Medicare Advantage regulations and guidance regarding Medicare Part D, such as CMS regulations and HPMS memos.
•    Monitor CMS guidance and transmittals to ensure compliance with all requirements.
•    Prepare and submit required compliance reports to regulatory authorities as necessary
•    Implement and maintain workflows and required ancillary documents for CMS Part C & D Data Validation, and other activities as required.
•    Conduct regular audits of pharmacy operations, claims processing, formulary management, and other areas to identify compliance risks and ensure adherence to P&Ps.
•    Submission of compliance reports to the Pharmacy Director and other stakeholders.

3.    Drug Utilization Review (DUR) 
•    Monitoring monthly DUR reports to meet the regulatory requirements of the DUR program. 
•    Monthly provider outreaches based on the review of DUR reports and collaboration with the pharmacists.  
•    Assist the pharmacists in quarterly provider outreaches including developing criteria, letter creation, and mailing. 
•    Review of retrospective drug utilization data for possible identification of Fraud Waste and Abuse (FWA). 

4.    Pharmacy Benefit Manager (PBM) Oversight
•    Monitoring the compliance of the PBM with contractual obligations and regulatory requirements.
•    Ensuring that the review, coding, and quality control of formulary changes occur in an appropriate, accurate, and timely manner.
•    Collaborating to address compliance issues and ensure alignment with contractual obligations.
•    Monitors daily issue/response files with PBM for claim resolution and outreach PBM for refills, claim reprocessing, and to members to provide status of intervention.
•    Maintains docu