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About the Role

Centene is seeking a clinical professional to join their Medical Management/Health Services team to support their 28 million members. The role offers a fresh perspective on workplace flexibility and competitive benefits.

Responsibilities

• Reviews and processes formulary change requests from Health Net plans.
• Submits and maintains formulary change requests to Health Net’s pharmacy claims processor.
• Generates, maintains, and reviews Formulary Status Grids.
• Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance.
• Assists Clinical Pharmacist with formulary database maintenance and updates to company website.
• Performs a variety of assignments required for pharmacy audit and recovery functions.
• Reviews paid claims for quantity and/or billing discrepancies.
• Corresponds with pharmacies as needed to communicate review findings.
• Faxes inquiries to pharmacies related to review findings.
• Answers incoming calls and responds appropriately to faxed correspondence from pharmacies.
• Updates Access database with incoming phone calls, faxes, and e-mails.
• Takes member inquiry calls for benefit questions including prior authorization requests.
• Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position.
• Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request.
• Processes member submitted claims.
• Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim.
• Assigns, enters, and documents prior authorizations into the appropriate claims processing system.
• Answers phone calls for prior authorization inquiries.
• Researches and resolves issues using the appropriate reference material.
• Responsible for knowing and interpreting pharmacy and medical benefits.
• Reviews and processes PDE files.
• Assists in pharmacy claims corrections projects.
• Performs audits and quality checks on active prior authorizations claims.
• Assists with identifying and correcting eligibility and group issues.
• Processes member claims.
• Acts as a liaison to internal and external departments for SHP pharmacy.
• Resolves operational issues, including issues from Prior Auth, Appeals and Grievances, and Member/Provider Services.
• Prepares and reviews various operational reports and audits.
• Manages SHP formulary functions, including quarterly formulary updates to website, database, and benefit maintenance.
• Maintains prior authorization database files.
• Processes Medi-Cal DMR.
• Assists with SHP clinical projects.
• Assists with Medi-Cal prior authorizations.
• Assists in the implementation of regulatory changes.
• Participates in maintaining consistent processes/methods for development, implementation, communication, and training on new/updated policies and procedures.
• Participates with Business Units/departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into P&Ps that span multiple departments.
• Provides support and monitoring to ensure compliance of First Tier, Downstream and Related Entities (FDRs).
• Assists with department preparation for internal and external audits (building case files, universes, evidence of compliance, and other documentation as needed).
• Identifies the validity of an appeal.
• If not a valid appeal, sends request to the correct department.
• Verifies drug, dosage, quantity, provider, and diagnosis information.
• Researches using formularies and prior authorization criteria to verify if additional information is needed.
• If additional information is needed, reaches out to providers and members and communicates clearly what information is needed.
• Performs other appeal tasks as assigned.
• Tracks and triages coverage determination and/or prior authorization requests submitted from providers and determines if a pharmacist review is required.
• Obtains verbal authorizations and requests detailed clinical information from prescribers.
• Approves coverage determination and/or prior authorization requests based on defined criteria.
• Enters and documents coverage determination and/or prior authorization request decisions into the PBM system and notifies providers and/or members.
• Responds to client inquiries regarding authorization approvals and PBM online applications.
• Refers coverage determination requests for specialty drugs to delegated vendor or client for processing.
• Contacts providers for additional information to facilitate coverage determination reviews.
• Notifies physicians, providers, and members of coverage determination request decisions.
• Performs other duties as assigned.
• Complies with all policies and standards.

Requirements

• High School diploma or GED required.
• 1 year Pharmacy Technician experience.
• Customer Service/retail experience preferred.

Skills

• Pharmacy Technician
• Customer Service
• Retail
• Formulary Management
• Pharmacy Audit and Recovery
• Pharmacy Service Center
• Medicare Part D/Part B
• Appeals
• Medicare Part D Operations
• State Health Programs Pharmacy Operations
• Prior Authorization

Location

• Remote
• Hybrid
• Field
• Office

Work Type

• Remote
• Hybrid
• Field
• Office
• Full-time

Experience Level

• 1 year Pharmacy Technician experience

Education Level

• High School diploma or GED

Salary/Compensations

• Competitive pay
• Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.
• Total compensation may also include additional forms of incentives.

Benefits

• Health insurance
• 401K
• Stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work

About the Company

• Centene is a diversified, national organization.
• Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.

Equal Opportunity

• All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
• Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.