This position will be responsible for answering requests for information, prior authorization, or help from pharmacy providers enrolled in the WV Bureau for Medical Services Medicaid Prescription Drug Program, Molina Medicaid Solutions Inc., WV Public Employees
Insurance Agency (PEIA), and WVCHIPs via phone or fax. This position will review prescription drug claims to determine insurance coverage of the drug or prior authorization criteria. The position also reviews pharmacy help desk calls to help pharmacies with
claims that will not properly process. Incumbent will explain to the provider why a prescription drug claim is not being paid by the plan and will perform data entry if the claim can be approved. Incumbent will also provide resources to the providers to help
them understand the drug coverage limitations.
Duties & Responsibilities
Responsibilities are functional in nature, and performed under supervision. Specific tasks include, but are not limited to:
1) Serves as the initial and main point of contact for healthcare providers serving the population of the WV Bureau for medical Services and WV Public Insurance Agency.
2) Provides excellent customer service through interaction with pharmacies and other healthcare providers.
3) Communicates clearly and concisely over phone, fax, or electronic mail in a professional manner.
4) Evaluate Help Desk and prior authorization requests using established guidelines, and enters approved requests into mainframe computer. Requests which require therapeutic judgment are referred to attending pharmacist.
5) Research provider inquiries using all available resources.
6) Perform callbacks to providers’ inquiries when necessary.
7) Documents all communications and required information in the appropriate database.
8) Assists Program Director/Pharmacist with administrative details of the program. Gathers, coordinates, and develops materials needed for enhanced quality of the program.
9) Responds to request for information from state, federal, or other governmental agencies and departments, and college or other University affiliates.
10) Assists Program Director/Pharmacist with special projects as needed.
11) Composes correspondence requiring a high degree of knowledge and familiarity of the program.
12) Performs research or statistical work in the compilation of reports involving the administrative activities of the program.
Position reports to the Unit Coordinator, Rational Drug Therapy Program.
Job is physically comfortable; individual is normally seated and has discretion of walking, standing, etc. May occasionally lift light-weight objects weighing less than 25 pounds. Work will require daily use of microcomputer, keyboard, printer, fax, copier,
telephone, and other related office equipment. Incumbent must have good hand/eye coordination and excellent speech patterns.
Works in standard office atmosphere with shared space and equipment. Incumbent is responsible to know and comply with all safety procedures.
Education and/or Experience
1) Associate’s degree or equivalent;
2) Experience and knowledge of symptoms, drug properties and interactions, and preventive health-care measures;
3) An equivalent combination of education and experience.
Certifications, Licenses, Registrations
1) Licensed pharmacy technician or have passed an equivalent examination.
Skills, Knowledge, Abilities
1) Strong mathematical skills necessary to perform financial and dosage calculations.
2) Demonstrated ability to work independently, exercising judgment.
3) Demonstrated ability to organize information and draw logical conclusions.
4) Demonstrated ability to plan, organize, and set priorities regarding the work to be accomplished.
5) Demonstrated excellent oral and written communication skills. Outstanding people skills, including a positive attitude, outgoing personality, and the ability to effective deal with all types and levels of people in a positive manner.
6) Demonstrated ability to maintain confidential information.
7) Skilled at using a microcomputer and related software, including Microsoft Office Software (Word, Excel, PowerPoint, etc.).
8) Skilled at using mainframe/microcomputers for Internet data collection, electronic mail, and other software.
9) Ability to read and write in English.
10) Ability to operate standard office equipment.
11) Ability to learn scientific or specialized terminology specifically relating to Pharmacy and Medicaid programs.
12) Knowledge of prescription drug information (i.e., generic and brand names, class of drugs).
13) Knowledge of pharmacy operations and insurance billing processes associated with retail pharmacy operations.
14) Knowledge of symptoms, drug properties and interactions, and preventive health-care measures
15) Ability to follow guidelines and convey information in an accurate manner.
16) Ability to be flexible and work in an environment with frequent rule changes.
1) Technical skills – Strives to continuously build knowledge and skills; pursues training and development opportunities; assess strengths, weaknesses, and shares expertise with others.
2) Problem solving – Gathers and analyzes information, identifies problems, develops alternatives, uses reason even when dealing with emotional topics and works well in groups and resolves matters timely.
3) Internal & External Customer Service – Manages difficult or emotional matters with objectivity and openness; responds promptly to needs and requests for service and assistance; meets commitments and dates, notifies others if change occurs; provides, solicits
and applies feedback; and builds goodwill through balanced contributions, positive approach, respect and support of others.
4) Communications – Demonstrates group presentation skills, participates in meetings, listens and gets clarification, is responsive and speaks clearly and persuasively in positive and negative situations. Writes and edits clearly and informatively, varies style
to meet needs, presents numerical data effectively, and able to read and interpret written information.
5) Organizational Support – Aligns work and develops strategies to meet organizational goals; seeks to improve and promote quality; demonstrates accuracy and thoroughness; and upholds organizational expectations and values.
6) Self-Management – Responds to management direction; resourcefully adapts to changes in work environment and circumstances; responds well under pressure and manages competing demands; takes calculated risks, asks for and offers help when needed; exercise
discretion and sound judgment; is tactful and responsible for own actions. Adheres to work schedule and complies with leave management responsibilities.
- AA/EOE/Minorities/Females/Vet/Disability/E-Verify Compliant Employer.
- Please view Equal Employment Opportunity Posters provided by OFCCP
- The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access
to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure
is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information.
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