MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.Position OverviewThe Prior Authorization Review Technician is responsible for inputting, providing notification for and reviewing prior authorization requests. The Prior Authorization Review Technician is also responsible for entering and auditing overrides input in the Pharmacy Adjudication system, answering member inquiries and assisting in all relevant Pharmacy department deliverables.
Job Description- Inputs all received medical benefit and pharmacy benefit prior authorization requests into our processing platforms, ensuring accurate transcription of all information
- Reviews and provides recommendations for select prior authorization requests following internal guidelines and criteria for review
- Answer inquiries from, but not limited to, members, providers and pharmacies received from our pharmacy call center line
- Provides verbal notification of prior authorization decision and inputs accurate medication overrides in the pharmacy adjudication platform
- Performs audit of vendor-inputted medication overrides in the pharmacy adjudication platform
- Assists in pharmacy case management activities
- Supports departmental quality initiatives
- Answers all triaged inquiries regarding MetroPlusHealth Pharmacy and Medical Benefit
Minimum Qualifications- Associate's degree with four years' experience as a Pharmacy Technician required or
- A satisfactory equivalent combination of education, training, and experience
- Pharmacy experience in a managed care environment preferred
- Experience in auditing preferred
- Experience in government programs (Medicare, Medicare Part D, and Medicaid) preferred
- Proficiency with MS Word, Excel, and PowerPoint is required.
- Proficiency with MS Access is preferred.
Licensure and/or Certification Required:
- PTCB or ExCPT Pharmacy Technician Certification, required
Professional Competencies:
- Integrity and Trust
- Customer Focus
- Functional/Technical Skills
- Position requires excellent organizational, teamwork, interpersonal, time management, written and verbal communication skills