Hours: Shift Start Time: Variable
Shift End Time: Variable
AWS Hours Requirement: 8/40 - 8 Hour Shift
Additional Shift Information: Full Time - Day Shift
Weekend Requirements: As Needed
On-Call Required: No
Hourly Pay Range (Minimum - Midpoint - Maximum): $29.403 - $36.754 - $44.104
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
This position is responsible for efficiently reviewing and verifying that appropriate drug prior authorizations are obtained by clinic staff in a way that best serves patients and prescribers in an outpatient hospital setting.
Duties and responsibilities include coordinating with prescribers, clinical pharmacy team members, and payers to ensure appropriate reimbursement and drug utilization. This member is expected to work effectively and constructively with all health care team members.
Required Qualifications H.S. Diploma or Equivalent3 Years experience in specialty pharmacy, home infusion, or other prior authorization process setting. Or 3 Years experience with managed care, PBM, Medicare Part D, Medicaid, or Commercial Health Insurance.California Pharmacy Technician License (TCH) - CA State Board of Pharmacy - REQUIRED Other Qualification Requirements An active certificate from Pharmacy Technician Certification Board (PTCB) - Preferred Preferred Qualifications: Experience working with controlled substances Essential Functions Drug Utilization Responsibilities: Efficiently screens payor-specific requirements to ensure that most cost-effective therapies are prescribed i.e. formulary preferred agents. Coordinates with healthcare team to initiate therapy switch to preferred equivalent therapy when necessary to ensure optimal reimbursement and appropriate drug utilization. Reviews drug utilization and reimbursement trends and recommends applicable process improvement opportunities. Participates in pharmacoeconomic initiatives in collaboration with system pharmacy services. Participates in initiatives aimed to reducing overall financial burden on patient and health system while maintaining highest quality of care.Prior Authorizations Assessment and Verification: Coordinates effectively with health care team members as applicable to obtain comprehensive information for the prescribed therapies to assess appropriate drug utilization. Reviews patient insurances to assess most cost-effective covered therapies and any applicable prescribing restrictions. Assesses financial risk distributions based on health insurance requirements and provides appropriate information on alternate therapies, as needed. Acts as a resource for the Prior Authorization Service and provides technical assistance on patient's coverage, authorization guidelines and procedures, claims research, and relevant department operating procedures. Clearly communicates outcome of prior authorizations to the healthcare team in a timely manner, along with any applicable recommendations. Coordinates with the Patient Assistance Team to ensure patients with financial hardship are referred to the program.Professional Development: Maintains current knowledge and understanding of revenue cycle operations, third party reimbursement procedures and regulations, payer relations, claims adjudication, contractual claims processing, medical terminology, regulatory statutes related to managed-care and outpatient pharmacy practices and an understanding of the 340B Drug Discount Program. Participates in educational programs to meet mandatory requirements and identified needs with regard to job responsibilities and personal growth. Shares learned principles and ideas from relevant resources and outside programs with patient care team members to help maintain cost effective drug utilization and formulary management. Assists other healthcare team members in keeping up with managed care policies specifically relating to drug utilization and reimbursement trends.Communication and Teamwork: Consistently demonstrates self-motivation, cooperation, teamwork, initiative and flexibility toward the fulfillment of organizational and departmental goals by: Assisting co-workers with tasks. Providing training and guidance to others who need information and data about assigned projects. Meeting established deadlines and completing special projects as assigned. Accurately recording and maintaining documentation for effective communication and hand-off. Setting work priorities, goals, and objectives in consultation with supervisor. Representing department and Sharp HealthCare in a professional and competent manner. Knowledge, Skills, and Abilities Computer skills required with an intermediate to advanced proficiency in Microsoft Office Suite including Word, Power Point, and Excel.Ability to effectively communicate with patients and health care team members.Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.
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