Pharmacy Utilization Management Specialist

🔥 1 minute ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $24 - $36 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

💊 Pharmacist

🚫👨‍🎓 No degree required

👻 Ghost score 0%

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Point32Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Point32Health is a leading nonprofit health and well-being organization that provides health coverage and services for individuals at all life stages. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a variety of health plans, programs, and services encompassing medical, pharmacy, wellness, and behavioral health. Point32Health is committed to health equity and has been recognized for its inclusive practices, earning distinctions in areas such as health equity, disability inclusion, and LGBTQ+ workplace inclusion. With a focus on innovative solutions and high-quality coverage, Point32Health strives to create a better healthcare experience for its members and communities.

📋 Description

• Set up and process drug prior authorization cases received by fax, electronic prior authorization, phone, and email • Review cases to ensure regulatory, accreditation, and turnaround-time requirements are met • Document case notes for prior authorizations requiring pharmacist or medical director review • Run test claims for approved authorizations • Contact members and providers as necessary • Communicate with providers through the department phone queue and resolve provider inquiries • Perform daily quality checks for compliance • Manage the Pharmacy Utilization Management team email inbox • Manage electronic prior authorization requests • Submit process improvements • Perform other assigned roles, duties, and projects

🎯 Requirements

• Certified Pharmacy Technician (CPhT) • High School Diploma or GED • Associate's degree in Healthcare, Nursing, or a related area or equivalent experience • Minimum 2 years of pharmacy experience • Experience in managed care/PBM setting preferred • Software/database experience with RxClaims and PAHub preferred • Proficient in MS Office—Excel, Word, and PowerPoint preferred • Ability to prioritize medical and pharmacy drug prior authorization requests according to guidelines and turnaround times • Ability to process high volumes of requests accurately • Good working knowledge of medical terminology • Ability to work independently and as part of a team • Ability to exercise appropriate judgment while following rules and regulations • Ability to work under normal office conditions and from home as required • Ability to work extended hours, including early mornings, evenings, weekends, or extended workdays as required • Flexibility with work schedule

🏖️ Benefits

• Medical, dental and vision coverage • Retirement plans • Paid time off • Employer-paid life and disability insurance with additional buy-up coverage options • Tuition program • Well-being benefits • Full suite of benefits to support career development, individual & family health, and financial health • Variable pay eligibility