Who We Are
Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health .
Job Summary
Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management (UM) Specialist is responsible for setting up and processing cases in the various applications for drug prior authorization (PA) requests.
Job Description
Key Responsibilities/Duties – what you will be doing:
Performs full case set up from fax, ePA, phone and email prior authorization requests
Upon case set up, a full case review is performed ensuring all applicable regulatory and accreditation requirements and turnaround times are met
Documents all relevant case notes for PAs (prior authorizations) requiring additional review by a pharmacist or medical director
Run test claims for approved authorizations and reach out to members and providers as necessary
Communicates with providers via department phone queue to process phone PAs and resolve provider inquiries
Additional tasks include performing daily quality checks to ensure compliance, managing the Pharmacy UM team email box, responding to provider inquiries, managing electronic prior authorization (ePA) requests, submitting process improvements, among others
Performs other roles/duties and projects as assigned
Qualifications – what you need to perform the job:
Certification and Licensure
Certified Pharmacy Technician (CPhT)
Education
Required (minimum): High School Diploma or GED. Associate's degree in Healthcare, Nursing, or a related area or equivalent experience.
Experience
Required (minimum): 2 years of pharmacy experience
Preferred: Experience in managed care/PBM setting. Software/Database experience - RxClaims, and PAHub
Skill Requirements
Proficient in MS Office - Excel, Word, and PowerPoint Preferred
Ability to prioritize work when processing medical and pharmacy drug PA requests per guidelines and within specific turnaround times
Ability to process high volumes of requests with great accuracy
Attention to detail and the ability to handle multiple demands, as well as balance multiple priorities in a fast-paced environment
Good working knowledge of medical terminology
Must be able to work independently, and as part of a team. Regular interface with various levels of staff and management is required.
Must be able to exercise appropriate judgement as necessary, following all rules and regulations where required
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):
Must be able to work under normal office conditions and work from home as required.
Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
May be required to work additional hours beyond standard work schedule.
Some early mornings, evenings, weekends, or extended workday may be required as program dictates. Must have flexibility with work schedule.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are…