JOB SUMMARY:
The Pharmacy Technician for American Health Plans is responsible for activities related to member access in the area of claims adjudication appropriateness and operations performed by the Plan’s Pharmacy Benefit Manager for a Medicare Advantage Institutional Special Needs Plan (I-SNP).
ESSENTIAL JOB DUTIES:
To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation.
- Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting
- Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time.
- Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment.
- Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines.
- Ensure proper coordination of benefits (COB), hospice billing considerations, and Part A/B vs Part D determinations when applicable.
- Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff.
- Gather and submit required documentation for PA review and ensure completeness to minimize delays.
- Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers.
- Serve as primary billing and claims contact for contracted network and long-term care pharmacies.
- Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues.
- Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes.
- Support transitions of care by ensuring medication access and clean claim processing for new or discharged members.
- Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies.
- Accurately document all claim interventions, communications, and resolutions in the plan’s system.
- Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing.
- Identify trends in claim rejections or PA delays and escalate systemic issues to leadership.
- Monitor daily billing and claims work queues and meet productivity and turnaround time expectations.
- Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams.
- Support process improvement initiatives to enhance claims efficiency and member access to medications.
- Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing
- Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes
- Coordinate clinical reporting
- Follow-up and solve open items in a timely manner
- May be assigned to work on special projects and business initiatives
- Other duties as assigned
JOB REQUIREMENTS:
- Proficient with Microsoft Suite applications
- Ability to navigate multiple systems
- Strong analytical skills
- Proficient communication and presentation skills
- Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements
- Successful completion of required training
REQUIRED QUALIFICATIONS:
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Education:
- High school diploma or equivalent
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Experience:
- Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience
- Experience in planning and implementation
- Experience working pharmacy claims, rejections, and PA’s
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License/Certification(s):
- Pharmacy Technician certification preferred
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