Pharmacy Technician

Pharmacy Technician

The Pharmacy Technician supports multiple pharmacy operations, including formulary management, pharmacy audit and recovery, pharmacy service center functions, prior authorization, Medicare Part D and Part B operations, state health programs pharmacy operations, oversight and audit support, and appeals. Using established guidelines, this role reviews and processes requests related to prescription drugs and pharmacy benefits, researches and resolves issues, and collaborates with clinical pharmacists and other healthcare professionals to ensure accurate, compliant, and timely handling of pharmacy benefits and claims.

Responsibilities:

• Review and process formulary change requests from health plans in accordance with established guidelines.
• Submit and maintain formulary change requests with the pharmacy claims processor and ensure accurate updates.
• Generate, maintain, and review formulary status grids to support accurate benefit administration.
• Use reports to perform audits and quality checks on current formulary status to ensure accuracy and contract compliance.
• Assist clinical pharmacists with formulary database maintenance and updates to the company website.
• Perform a variety of assignments to support pharmacy audit and recovery functions.
• Review paid claims for quantity or billing discrepancies and correspond with pharmacies to communicate findings.
• Fax inquiries to pharmacies related to review findings and document responses.
• Answer incoming calls and respond to faxed correspondence from pharmacies in a timely and professional manner.
• Update an Access database with information from incoming phone calls, faxes, and emails.
• Take member inquiry calls related to pharmacy benefits, including prior authorization requests.
• Maintain expert knowledge of Medicare pharmacy benefits and formularies, including applicable regulations relevant to the role.
• Educate members on their specific pharmacy benefits and present options, including submission of prior authorization requests.
• Process member-submitted claims accurately and efficiently.
• Review requests from physicians and pharmacies for prescription drugs that are non-formulary, require prior authorization, exceed quantity or cost limits, or need assistance with online claim processing.
• Assign, enter, and document prior authorizations into the appropriate claims processing system.
• Answer phone calls regarding prior authorization inquiries and provide clear, accurate information.
• Research and resolve issues using appropriate reference materials and resources.
• Interpret and apply pharmacy and medical benefit information when reviewing requests.
• Review and process Part D event (PDE) files for Medicare operations.
• Research and resolve Medicare Part D issues using appropriate reference materials.
• Assist with pharmacy claims correction projects to ensure accurate claim outcomes.
• Perform audits and quality checks on active prior authorization claims.
• Assist with identifying and correcting eligibility and group issues related to pharmacy benefits.
• Process member claims in accordance with established policies and procedures.
• Serve as a liaison to internal and external departments for state health programs pharmacy operations.
• Support operational issue resolution, including issues originating from prior authorization, appeals and grievances, and member or provider services.
• Prepare and review various operational reports and audits related to state health programs.
• Perform formulary management functions for state health programs, including quarterly formulary updates to the website, database, and benefit maintenance.
• Maintain prior authorization database files for state health programs.
• Process Medi-Cal DMRs and assist with Medi-Cal prior authorizations as needed.
• Assist with clinical projects related to state health programs.
• Assist in implementing regulatory changes impacting pharmacy operations.
• Participate in maintaining consistent processes and methods for developing, implementing, communicating, and training on new or updated policies and procedures.
• Collaborate with business units and departments to ensure end-to-end process connectivity and effective handoffs across policies and procedures.
• Provide support and monitoring to help ensure compliance of first-tier, downstream, and related entities.
• Assist with department preparation for internal and external audits, including building case files, universes, evidence of compliance, and other required documentation.
• Identify the validity of appeals and route non-valid appeals to the appropriate department.
• Verify drug, dosage, quantity, provider, and diagnosis information for appeal cases.
• Research formularies and prior authorization criteria to determine if additional information is needed for appeals.
• Contact providers and members to obtain additional information for appeals and clearly communicate what is required.
• Perform other appeal-related tasks as assigned.
• Track and triage coverage determination and prior authorization requests submitted by providers for Medicare Part D and Part B.
• Determine when pharmacist review is required for coverage determination or prior authorization requests.
• Obtain verbal authorizations and request detailed clinical information from prescribers.
• Approve coverage determination and prior authorization requests based on defined criteria.
• Enter and document coverage determination and prior authorization decisions in the pharmacy benefit management (PBM) system.
• Notify providers and members of coverage determination and prior authorization decisions.
• Respond to client inquiries regarding authorization approvals and PBM online processes.
• Refer coverage determination requests for specialty drugs to delegated vendors or clients for processing.
• Contact providers for additional information to support coverage determination reviews.
• Perform other duties as assigned in support of pharmacy operations.

Essential Skills:

• High school diploma or GED.
• At least 1 year of experience as a Pharmacy Technician.
• Experience in pharmacy operations, including handling prescription drug and pharmacy benefit requests.
• Proficiency in data entry and accurate documentation in claims processing and related systems.
• Experience with prior authorization processes for prescription drugs.
• Ability to review and interpret formulary information and pharmacy benefit structures.
• Strong customer service skills, including handling member, provider, and pharmacy inquiries by phone and fax.
• Ability to research and resolve issues using appropriate reference materials.
• Strong attention to detail for audits, quality checks, and claim reviews.
• Ability to work within established guidelines and regulatory requirements.
• Valid Pharmacy Technician license (preferred).

Additional Skills & Qualifications:

• Customer service or retail experience.
• Experience with appeals related to pharmacy benefits and prior authorizations.
• Familiarity with Medicare Part D and Part B pharmacy benefits and related regulations.
• Experience with state health programs such as Medi-Cal and related pharmacy operations.
• Ability to work with databases, including updating and maintaining Access databases.
• Experience supporting audits, including preparing documentation and evidence of compliance.
• Ability to collaborate across departments and serve as a liaison for operational issues.
• Strong communication skills for educating members and communicating with providers and internal stakeholders.
• Comfort working with multiple systems, including PBM systems and claims processing platforms.

Work Environment:

The Pharmacy Technician works in a structured, process-driven environment focused on accurate and compliant administration of pharmacy benefits. The role involves frequent interaction by phone, fax, and email with members, providers, pharmacies, internal departments, and external partners. Daily work includes extensive use of computer-based systems, such as claims processing platforms, PBM systems, reporting tools, and databases like Microsoft Access. The position requires careful adherence to policies, procedures, and regulatory requirements, as well as participation in audits and process improvements. The environment emphasizes accuracy, documentation, and timely response to inquiries and requests, with responsibilities spanning formulary management, prior authorization, Medicare and state health program operations, audit support, and appeals handling.

Job Type & Location:

This is a Contract to Hire position based out of Washington D.C., DC.

Pay and Benefits:

The pay range for this position is $20.00 - $24.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k)