100% Remote Pharmacy Technician

100% Remote Pharmacy Technician

The Pharmacy Technician supports multiple pharmacy operations areas, including formulary management, pharmacy audit and recovery, pharmacy service center, Medicare Part D and Part B, appeals, state health programs pharmacy operations, and prior authorization. Working within established guidelines, this role reviews requests from physicians, medical groups, pharmacies, and members for prescription drug use and pharmacy benefits, researches and resolves questions and issues, and collaborates with clinical pharmacists and other clinical staff to ensure accurate, compliant, and timely processing of claims and authorizations.

Responsibilities

• Review and process formulary change requests from health plans in accordance with established procedures.
• Submit and maintain formulary change requests with the pharmacy claims processor to ensure accurate benefit configuration.
• Generate, maintain, and review formulary status grids to track current formulary positions.
• Use reports to perform audits and quality checks on formulary status for accuracy and contract compliance.
• Assist clinical pharmacists with formulary database maintenance and updates to the company website.
• Perform a variety of assignments related to pharmacy audit and recovery functions.
• Review paid claims for quantity and billing discrepancies and communicate findings to pharmacies.
• Fax inquiries to pharmacies related to review findings and follow up as needed.
• Answer incoming calls and respond to faxed correspondence from pharmacies regarding audit and recovery issues.
• Update Access databases with information from incoming phone calls, faxes, and emails.
• Take member inquiry calls regarding pharmacy benefits, including questions about prior authorization requirements.
• Maintain expert knowledge of Medicare pharmacy benefits and formularies, including relevant CMS regulations.
• Educate members on their specific pharmacy benefits and present options, including submission of prior authorization requests.
• Process member-submitted pharmacy claims accurately and in a timely manner.
• 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 related to prior authorization inquiries and provide clear, accurate information.
• Research and resolve prior authorization issues using appropriate reference materials and resources.
• Maintain thorough knowledge of pharmacy and medical benefits to interpret and apply benefit rules correctly.
• Review and process Medicare Part D PDE files in accordance with regulatory and internal standards.
• Research and resolve Medicare Part D operational issues using appropriate reference materials.
• Assist with pharmacy claims correction projects to ensure accurate payment and benefit application.
• Perform audits and quality checks on active prior authorization claims to verify compliance and accuracy.
• Assist with identifying and correcting eligibility and group configuration issues impacting pharmacy claims.
• Process member claims for Medicare Part D and related programs as needed.
• Act as a liaison to internal and external departments for state health programs pharmacy operations.
• Resolve operational 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 pharmacy operations.
• 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 DMR requests and related documentation.
• Assist with state health program clinical projects and initiatives.
• Assist with Medi-Cal prior authorizations, ensuring accurate and timely processing.
• Assist in implementing regulatory changes affecting pharmacy operations and benefits.
• Participate in maintaining consistent processes and methods for development, implementation, communication, and training on new or updated policies and procedures.
• Work with business units and departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into policies and procedures spanning multiple departments.
• Provide support and monitoring to help ensure compliance of First Tier, Downstream, and Related Entities (FDRs).
• Assist with departmental preparation for internal and external audits, including building case files, universes, evidence of compliance, and other documentation.
• Identify the validity of appeals and determine whether they meet criteria for formal appeal processing.
• Redirect non-valid appeals to the appropriate department for resolution.
• Verify drug, dosage, quantity, provider, and diagnosis information for appeal cases.
• Research formularies and prior authorization criteria to determine if additional information is required for appeal review.
• Contact providers and members to request additional information needed for appeals and communicate clearly about requirements.
• 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 clinical and benefit criteria.
• Enter and document coverage determination and prior authorization decisions into the PBM system and notify providers and members.
• Respond to client inquiries regarding authorization approvals and PBM online processing and refer specialty drug coverage determination requests to delegated vendors or appropriate parties.
• Contact providers for additional information to facilitate coverage determination reviews.
• Notify physicians, providers, and members of coverage determination and prior authorization decisions.
• Perform other duties as assigned in support of pharmacy operations, member service, and regulatory compliance.

Essential Skills

• High school diploma or GED.
• At least 1 year of experience as a Pharmacy Technician.
• Experience with pharmacy data entry and prior authorization processing.
• Ability to review and process formulary changes, prior authorizations, and appeals using established guidelines.
• Strong attention to detail for auditing claims, verifying information, and maintaining accurate records.
• Ability to research and resolve pharmacy benefit issues using formularies, criteria, and reference materials.
• Effective verbal and written communication skills for interacting with members, providers, pharmacies, and internal teams.
• Ability to manage inbound calls and faxed correspondence professionally and efficiently.
• Proficiency in using databases, including updating Access databases with call, fax, and email information.
• Understanding of pharmacy and medical benefits, including Medicare Part D and Part B benefit structures.
• Ability to interpret CMS regulations as they pertain to Medicare pharmacy benefits.
• Organizational skills to handle multiple tasks such as claims processing, audits, and prior authorization tracking.
• Customer service skills for educating members on benefits and guiding them through prior authorization processes.

Additional Skills & Qualifications

• Customer service or retail experience preferred.
• Valid Pharmacy Technician license preferred.
• Experience working with appeals and grievances in a pharmacy or health plan environment.
• Familiarity with state health programs such as Medi-Cal and related pharmacy operations.
• Experience supporting internal and external audits, including preparation of case files and compliance documentation.
• Ability to participate in policy and procedure development, implementation, and training.
• Comfort working across multiple business units and departments to ensure coordinated processes.
• Experience with formulary management, including maintaining databases and updating websites.

Job Type & Location

This is a Contract to Hire position based out of Atlanta, GA.

Pay and Benefits

The pay range for this position is $18.00 - $20.00/hr.

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) Retirement Plan Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-