Medicare Advantage Benefits Pharmacy Tech

Pharmacy Health Plan Services Assistant

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

This position is responsible for assisting the Pharmacy Health Plan Services area in the management of the Medicare Advantage Part D prescription benefits. Under the supervision of the Health Plan Pharmacy Manager and/or Supervisor, this position is primarily responsible for triaging and/or resolving pharmacy services phone calls, audits and monitoring functions that help ensure prescription benefits are administered cost effectively, timely, accurately and in compliance with CMS standards. This position also includes, processing coverage determinations per Medicare Part D program regulations and assisting the Health Plan Pharmacy Services department with the management of Kelsey-Seybold Clinics' Pharmacy Quality Initiatives (i.e. MTMP, Hospital Discharge, RXQI, and Adherence). Additional activities may include scheduling appointments and monitoring functions that help ensure Pharmacy Initiatives are administered efficiently, accurately and in compliance with the departments' standard operating procedures. This position may conduct outbound calls regarding patient adherence to medications and assist patients to refill medications in a prompt and courteous manner utilizing a PC. This position is also responsible for general clerical duties which include but are not limited to member mailings, verifying addresses for return mail, data entry, processing collection letters and documenting member outcomes. This position confirms appointments and handles cancellations in a timely, efficient and courteous manner. The employee in this position should be able to provide comprehensive service in order to facilitate a resolution to caller requests and triage calls to the appropriate team members when necessary. The employee should acquire and maintain computer skills to effectively utilize software and Windows based programs as well as be able to quickly learn processes and put into practice learned principles.

Primary Responsibilities:

• Aide in developing and maintaining the daily schedule for program staff. Schedule appointments utilizing a PC and appropriate software systems to access the patient's chart and medication records per established processes and policies. Confirm appointments in advance to decrease same day cancellations. Cancel and reschedule appointments prior to appointment date at the request of the patient or supervisor
• Discuss with patients the potential for a pharmacist assessment to be conducted for a therapeutic interchange, importance of annual physical, and/or long term supply of medication
• Answer inbound calls and conduct outbound calls regarding patient medication adherence and assist patients to refill medications in a prompt and courteous manner utilizing a PC
• Answer inbound calls and conduct outbound calls regarding processing of coverage determinations timely and accurately. Review medical information essential for determination to be conducted. Properly document data into software program(s). Enter overrides in appropriate systems to process payment. Generates letters and/or reports
• Serve as Part D specialist for KCA member services. Answer pharmacy, member, and KCA member service questions verbally and in writing regarding formulary, benefits and pharmacy claims adjudication at the point of sale. Process information promptly and accurately. Triage questions via investigation into eligibility, medical and pharmacy claims systems
• Responsible for conducting pharmacy services timely through EPIC CRMs for Rx Assistance, prospective member and formulary intervention. Communicate with members and other healthcare personnel to discuss formulary and educate about health plan prescription drug benefits. All calls are documented in EPIC CRM module
• Properly enter accurate data to document outcomes in the appropriate software systems. Gather initial information essential for a pharmacist assessment to be conducted. Confirm and update medication and demographic information as necessary. Demonstrate commitment to meeting the expectations & needs of program's participants. Properly enters data into software program. Generate any necessary letters and/or reports
• Daily monitoring and reporting of plan eligibility to ensure members have access to Part D benefits
• Perform audits timely and accurately related to Part B claims processing including but not limited to part b drugs, diabetic supplies, MOOP and EOBs
• Perform audits timely and accurately related to PBM oversight including but not limited to Part D EOBs, FIR, Prompt Pay, LTC Reprocessing, Transition Benefit and Yearly Claims Testing
• Perform audits timely and accurately related to formulary processing including but not limited to formulary changes, Medicare Drug Plan Finder, rejection report
• Perform audits timely and accurately related to internal processes including but not limited to COB Testing, Vaccine Reports, Manufacturer Assts, WCMSA and MWBE
• Perform audits timely and accurately related to coverage determination
• Daily, weekly and quarterly monitoring and maintenance of Pharmacy Quality Initiative Programs, work queue's and follow up. Demonstrates commitment to meeting the expectations and needs of program's participants. Ensures prompt and courteous customer service by all Health Plan Pharmacy Services personnel. Process daily and return mail and member mailings. Provides clerical support for Part D duties and audits and any other duties deemed necessary to support pharmacy activities. Responsible for adherence to federal and state Pharmacy laws
• Departmental cross training to support all existing and future Pharmacy Initiatives as needed. Interface with clinical providers to fulfill patients' needs in life threatening or clinical situations. Troubleshoot issues. Reports risks to management timely and accurately

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School diploma or GED from an accredited program
• TSBP Registered Pharmacy Technician
• 6+ months operational pharmacy benefit experience OR 6+ months experience in a high volume call center OR 6+ months of customer service experience OR 6+ months retail pharmacy experience
• Proficient 2 with computer applications that including, but not limited to: Microsoft Word, Excel, and Access
• Proven good Alpha/Numeric data entry skills with minimal errors
• Proven excellent customer service, telephone etiquette skills, and active listening skills
• Demonstrates strong problem solving and analytical skills
• Type 20 WPM. 10 key by touch
• Proven communication skills, professional appearance, and ability to work effectively in a fast paced work environment
• Proven ability to speak, write and understand the English language
• Proven detail oriented with excellent verbal and written communication skills

Preferred Qualifications:

• Some college or technical school
• 2+ years of Medicare Part D experience
• 2+ years of high volume call center experience
• 2+ years of HMO 3rd party managed care experience
• Auditing experience
• Proven ability to exercise good judgment during high call volume while maintaining a professional attitude
• Bilingual English/Spanish

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $16 - $29 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.