POSITION SUMMARY
This position reports to the Clinical Supervisor - Pharmacy Coverage Determinations. The Clinical Specialist I – Pharmacy Coverage Determinations is responsible for reviewing, evaluating, communicating, documenting, tracking, and making determinations within the protocol for pharmacy benefit coverage determination requests such as requests for formulary exceptions, prior authorization (PA), step therapy (ST), and quantity limit (QL) exceptions, and override processes for delegated utilization management (UM) products and services based upon regulation and defined procedures. The Clinical Specialist I – Pharmacy Coverage Determinations will review and evaluate coverage determination requests for the clinical opportunity to address the appropriateness of therapy, clinical interventions, generic substitution, or therapeutic interchange opportunities with potential cost savings outcomes, and/or interventions. This individual will focus on initiating, supporting, and continuing cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related clinical management and cross-departmental functions that focus on improving the health of members while reducing overall health care costs. They will be responsible for providing clinical support services to plan sponsors contracting for clinical services. They will review medication request guidelines for clinical appropriateness and operational efficiency through knowledge of the practice of pharmacy, including laws, rules, and regulations of the various US states, the usual methods of filling prescriptions, and common habits of the profession. The Clinical Specialist I – Pharmacy Coverage Determinations requires strong attention to detail, empathy, and professionalism in every interaction, and a strong commitment to professional physician interactions.
ESSENTIALS ROLES AND RESPONSIBILITIES
Responsible for the accurate and timely review, disposition, documentation, and system input at the drug-specific level of submitted prescription UM requests. Accountable for processing PA requests according to the urgency of the medication or the member’s health condition to avoid member disruptions following state, federal, and Medicare Part D standards with an understanding of Medicare Coverage under Part D versus B and Appeal cases. Process and time stamp all PA requests daily from fax or other means. Monitor incoming faxes and uploads all documents to the corresponding patient’s profile. Monitor the BaCMan Alert Application to ensure proper management of pharmacy benefit coverage determination requests. Change the Alert status to In Process when a prescription and/or justification is received by fax. Responsible for faxing PA forms to providers, physicians, and members upon request. Responsible for assisting in faxing or calling prescriber and/or patients for various prescription clarification and UM-related questions.Conduct an in-depth review of patient histories, medical records, using professional judgment to determine medical necessity and appropriateness. Obtain additional/missing information from the appropriate source via verbal or written communication, if necessary, to process PA requests. Document all contact/attempts to contact and information needed to complete a case. Initiate and continue direct communication with health care providers involved with the care of the member to obtain complete and accurate information. Utilize protocols, appropriate regulations, online clinical literature databases, and designated criteria along with clinical and medical knowledge, pharmaceutical knowledge of dosage forms and drug delivery systems, and utilization review to provide drug information support and research. Provide clinical literature documentation to support PA decisions as indicated by conducting a systematic procedure for performing a comprehensive literature search, and drawing appropriate conclusions based on a summary of a comprehensive literature search.Appropriately document and record all PA activities following departmental, regulatory, and legal standards and within the patient profile. Change the Alert status to Approved or Conditional Denial after completing the coverage determinations evaluation. Maintain an efficient, organized, and orderly tracking and recording system for PAs and clinical program files and ensure accurate case classification and coding using diagnosis and ICD-9/10 codes. Respond to all requests via timely and accurate written communication to the member’s physician, the member, and the pharmacy that detail the outcome of the request.Maintain appropriate system knowledge, including a comprehensive understanding of override processes and edits required to process a claim following policies and procedures.Responsible for creating approval and denial letters to patients and providers based upon standardized letters based upon the appropriate PA, length of therapy, and/or reasons for denial. Completed letters are then sent for quality assurance validation before compilation and sending. Refer cases not meeting criteria, protocols, or guidelines to pharmacist or physician review. Escalate requests to pharmacists when a request, question, or case requires extensive clinical review or denial. Understand when to escalate cases and to a pharmacist to interpret or provide direction on the case or question. Responsible for handling pharmacy and physician calls related to the coverage determination review process or protocols. Receive inbound calls and requests from prescribers and initiates outbound calls to providers (physicians and pharmacies) and members to communicate case dispositions. Address escalated calls and non-standard customer service-related issues. Respond in a timely, concise, professional, accurate, and detailed manner to inquiries in writing to Clients and Plan Sponsors who submit inquiries or cases to the Manage Engine Service desk or other means of communication. Determine the presence of any medication therapy problems in a patient's current medication therapy and identify the appropriate action. Support improved member outcomes by identifying opportunities for member education and Pharmacist intervention through the clinical intervention program opportunities. Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations.Meet or exceed departmental performance requirements consistently. Assist in the development and implementation of goals, objectives, plans, and policies to achieve selected clinical program service outcomes as established by the Clinical Director and Pharmacists. Carry out quality control measures and quality assurance programs for clinical services.Actively participate in assigned interdepartmental workgroups and committees. Effectively communicate with all levels of departmental staff, as well as members, clients, and healthcare professionals. Maintain an awareness of developments in the community and pharmaceutical fields that relate to job responsibilities and integrate them into practice.Understand PharmPix’s mission, vision, values, and culture. Support clinical and corporate initiatives. Take appropriate actions, assesses each situation, and follow through with the utmost attention to accurate communication. Work in conjunction with other members of the clinical staff to audit and resolve issues that occur during daily operations. Exhibit compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, PharmPix’s Code of Ethics, Standards of Conduct, and any applicable policies and procedures.Other projects and duties as assigned.This position allows for a career ladder progression with the levels of Clinical Specialist II and Clinical Specialist III positions.
TRAINING & EDUCATION
High-school diploma Pharmacy Technician Associate Degree from an accredited institution (where mandated by law)LICENSURE / CERTIFICATION
Nationally Certified Pharmacy Technician (CPhT) required.Current, valid, and unrestricted state or Puerto Rico Pharmacy Technician license/registry certificate.PROFESSIONAL EXPERIENCE
1 – 2 years clinical experience in a health care environment or at a pharmacy benefit manager.Open to newly licensed technicians.PROFESSIONAL COMPETENCIES
Knowledge:
General knowledge of pharmacology for major drug categories. Knowledge of Microsoft Access, Word, Excel, PowerPoint, and Outlook, as well as Internet Explorer. Knowledge of pharmaceutical products, drug names (brand/generics), dosage forms, and pharmacy terminology. Knowledge of Retail Pharmacy Operations and an understanding of insurance billing, third-party systems, point of sale, online pharmacy claims processing system experience preferred.Knowledge of the purpose, organization, and policies of community health care delivery and pharmacy regulations/regulatory agencies.Skills:
Excellent phone, written, listening, and follow-through skills.Skill in exercising a high degree of initiative, judgment, discretion, and decision-making to achieve organizational objectives. Skill in exercising judgment in applying, interpreting, and coordinating departmental policies and procedures. Strong analytical, customer service, problem analysis, decision-making, and verbal and written communications skills.Time Management Skills: Skill in establishing priorities and accomplishing tasks promptly.Abilities:
A demonstrated ability to establish and maintain quality control standards. Ability to accurately read and interpret physicians’ prescription orders, medical charts, and diagnostic test and laboratory results.Ability to calculate figures, rates, ratios, percentages, and amounts in all units of measure using whole numbers, fractions, and decimals.Ability to develop and maintain productive relationships with other internal departments, PharmPix clients, and other health care professionals. Ability to learn and convey medical and formulary technical information at the level of the client, member, or healthcare professional. Ability to follow guidelines for accurate member interventions while meeting or exceeding performance standards.Ability to organize and integrate organizational priorities and deadlines. Ability to prioritize, check for errors, and spot inaccuracies.Ability to see trends in utilization patterns.Ability to solve practical problems and deal with a variety of standards effectively using good problem solving and analytical skills.Ability to understand the importance of and maintain the confidentiality of all patient information.Fully bilingual English and Spanish (preferred).PHYSICAL AND MENTAL DEMANDS
The physical demands described here represent those that must be met by an employee to perform the essential functions of this job successfully. While performing this job's duties, the employee is regularly required to talk or hear, sit, stand, and walk. The position requires that up to 25 pounds of weight be lifted. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.ENVIRONMENTAL AND WORKING CONDITIONS
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. May require evening or weekend work.PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans
POSITION SUMMARY
The Financial Analyst reports to the Financial Analysis Manager and is responsible for preparing financial analysis, pricing models, data analysis and reports for the company and monitoring actual results and trends.
ESSENTIAL ROLES AND RESPONSIBILITIES
Prepare financial analysis and pricing models upon management request.Perform data analysis by collecting and analyzing data & patterns, presenting findings, facilitating informed decision-making and problem resolution.Prepare reports, analysis, and presentations requested by customers and management.Reconciles customer’s actual performance with contract terms and definitions on a monthly, quarterly and/or annual basis. Also, provide responses to submitted findings and perform corrections as necessary.Identifying trends in financial performance and provide recommendations for improvement.Provide support as needed during the monthly accounting closing cycle.Responsible for maintaining Client Side Pricing Tool, including but not limited to: updating contracted pricing, coordinating with IT department to make necessary programming requested by client or management, and perform testing.Coordinate with IT department the creation and validation of different reports required by management to analyze business trends and activities.Maintains technical knowledge by attending educational workshops, reviewing publications (NCPDP).Protect operations by keeping financial information confidential.Contributes to team effort by accomplishing related results as needed.Other tasks and responsibilities as required by Supervisor.TRAINING & EDUCATION
• BBA major in Finance or Accounting.
LICENSURE / CERTIFICATION
• CMA or CPA, preferred.
PROFESSIONAL EXPERIENCE
• Five (5) or more years of experience in a combination of financial analysis, reporting and accounting closing cycle.
• PBM and/or Medicare experience, preferred.
PROFESSIONAL COMPETENCIES
Knowledge:
• Expert Knowledge in MS Office, mainly Excel and Power BI.
• Basic SQL knowledge, preferred.
• Fully bilingual English and Spanish.
Skills:
• Strong analytical skills.
• Great presentation skills.
• Good oral and written communication skills.
Abilities:
• Excellent time management and organizational ability.
• Ability to multitask and meet constant deadlines.
• Adaptability to changing structures and situations.
PHYSICAL AND MENTAL DEMANDS
• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear, sit, stand, and walk.
• The position requires that weight be lifted, and force be exerted up to 25 pounds.
• Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
ENVIRONMENTAL AND WORKING CONDITIONS
• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Requires evening or weekend work
PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans
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The Pharmacy Help Desk Call Center Representative reports to the Pharmacy Help Desk Call Center Supervisor and is responsible to provide a customer service by telephone of incoming and outbound calls to providers, beneficiaries and pharmacies.
ESSENTIALS ROLES AND RESPONSIBILITIES
Answer incoming pharmacy calls regarding issues related to a claim transaction, reimbursement, payment, and other required information in accordance with PharmPix Pharmacy Help Desk Call Center performance metrics.Answer incoming providers’ and beneficiaries’ calls following Call Center scripts, in a timely matter and in accordance with PharmPix call center performance metrics.Answer incoming calls and perform outbound calls according to HIPAA and Pharmacy Laws Standards.Identify pharmacies, providers and beneficiaries needs, clarify information, research every issue and providing solutions.Document all inquiries in the Customer Service Management Applications such as, Service Desk, OneArk and email.Route the case to the corresponding internal department or the appropriate Health Insurance Carrier.Guide pharmacies, providers and beneficiaries regarding the process of claim transmission, reimbursement and payment.Constantly monitors the BACMAN Alert Application to ensure proper management of rejections at point of sale.Evaluate on an individual basis to determine if the patient meets the criteria for a coverage determination for alerts such as DURs (Drug Utilization Reviews), HMO (Health Maintenance Organization) among other rejections evaluations required by business.Identify system issues and route to the corresponding internal department.Make outbound calls to pharmacies, providers and beneficiaries if necessary.Support all Quality Management Program initiatives.Perform Special projects and/or other duties assigned by the Operations Manager and or Pharmacy Help Desk Call Center Supervisor.TRAINING & EDUCATION
Pharmacy Technician, Technical or Associate DegreeLICENSURE / CERTIFICATION
Puerto Rico Board of Pharmacy Technician Registry Certificate (CPhT), or prospect.PROFESSIONAL EXPERIENCE
1 - 2-year customer service or call center experience and healthcare environment (Preferable).PROFESSIONAL COMPETENCIES
Knowledge:
Fully Bilingual (Spanish / English written and verbal).PC skills (Microsoft System)/System oriented.Skills:
Strong customer service skills.Excellent phone, written, active listening and follow-through skills.Skill in analyzing situations accurately and taking effective action.Attention to details.Time Management Skills: Establishing priorities and accomplishing tasks in a timely manner.Ability to work with others to reach a solution.Be able to toggle between several software programs.Demonstrated effective organizational skills.Abilities:
Able to effectively interact with internal departments, PharmPix clients, members and other healthcare professionals.Ability to work with others to reach a solution.Be able to toggle between several software programs.Ability to work in a fast-paced environment and multitask.PHYSICAL AND MENTAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear, sitting, standing and walking.The position requires that weight be lifted and force be exerted up to 25 pounds.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.ENVIRONMENTAL AND WORKING CONDITIONS
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. Require evening or weekend work.PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans
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The IT Security Analyst plays a key role in safeguarding the organization's digital assets and ensuring information systems' confidentiality, integrity, and availability. In addition to monitoring, analyzing, and responding to security incidents and threats, the position oversees access control measures and manages permissions for the organization's corporate domain and applications. Collaborating with cross-functional teams, the IT Security Analyst assesses risks, implements security controls, and ensures compliance with industry standards and regulations.
ESSENTIAL ROLES AND RESPONSIBILITIES
User Account Management: Configure and manage user accounts, permissions, and access rights within the organization's IT systems, applications, and network resources.Access Control Inventory: Maintain a comprehensive inventory of all user permissions granted across various IT systems, applications, and network resources.Compliance Support: Support compliance efforts by ensuring user permissions management practices align with regulatory requirements, industry standards, and internal policies.Security Monitoring: Monitor security event logs, alerts, and notifications generated by security systems such as SIEM, IDS/IPS, and endpoint protection solutions.Incident Detection and Investigation: Detect, analyze, and investigate security incidents and anomalies identified through monitoring activities.Threat Intelligence: Utilize threat intelligence feeds to stay ahead of emerging threats and provide actionable recommendations for risk mitigation strategies.Security Controls Implementation: Support implementing security controls, policies, and procedures.Remediation Planning: Assist in implementing remediation plans based on findings from various security assessments.Risk Mitigation: Based on data analysis, research, and emerging technologies, provide recommendations for mitigating information security risks and improving security controls.Collaboration: Collaborate closely with team members to solve security-related issues and improve overall security posture.Other Responsibilities: Perform other job-related duties as assigned.EDUCATION & PROFESSIONAL EXPERIENCE
Bachelor’s degree in computer science, Information Technology, Cybersecurity, or a related field.2-4 years of hands-on experience in IT Security roles.Experience with security tools such as SIEM, Firewalls, Endpoint Protection Solutions, and permission management.Experience working in a highly regulated industry. (preferred)LICENSURE / CERTIFICATION
Technical certifications such as Security+, CySA+, Network+ or equivalent are preferred.PROFESSIONAL COMPETENCIES
Skills:
Excellent problem-solving and analytical skills with the ability to diagnose and resolve technical issues.Strong communication and interpersonal skills to provide effective technical support and collaborate with stakeholders.Ability to manage multiple tasks, prioritize, and meet deadlines in a dynamic environment.Strong, structured, process-driven, and analytical skills.Demonstrate skills in building relationships within departments and between departments. Good research skills.Knowledge:
Familiarity with IT Security frameworks (e.g., NIST CSF, CIS Controls)Proficiency in Microsoft Office: Excel, Word, Access, and Microsoft Outlook.Excellent knowledge of Customer Service best practices. Strong knowledge of computer hardware, software, and networking principles.Technical research and development knowledge are desired.Fluency in spoken and written Spanish and English.Abilities:
Understand existing and emerging technologies. Understand business practices, approaches, organization, politics, and culture. Demonstrate ability to work under pressure with compressed deadlines and multiple deliverables. Demonstrated ability to communicate ideas clearly and concisely to leadership.Ability to work well as a member of a team or alone. Willingness to take ownership of problems and follow through to completion.Ability to prioritize and manage time.Arrive at work promptly and consistently.Proven ability to work in an ambiguous environment and collaborate across multiple areas to achieve a common business objective.PHYSICAL AND MENTAL DEMANDS
The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully. While performing the duties of this job, the employee is regularly required to talk or hear, sit, stand, and walk.The position requires that the weight be lifted, and force is exerted up to 50 pounds.Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.ENVIRONMENTAL AND WORKING CONDITIONS
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. Require evening or weekend work.PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans
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