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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicare Part B and Medi-Cal prior authorization processes, including knowledge of pharmaceutical terminology and compliance with regulatory standards. Proficient in communication with healthcare providers and managing pharmacy benefit operations to support quality improvement initiatives.
Highest-signal resume keywords
Pharmacy Technician LicenseMedicare Part B AuthorizationUtilization ManagementPharmaceutical TerminologyMicrosoft Excel
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Prior Authorization ProcessingClinical ReviewChart Note AnalysisTyping Speed of 40 CWPMQuality Metrics Evaluation
Soft Skills
Organizational SkillsVerbal CommunicationWritten CommunicationInterpersonal SkillsCritical Thinking
Tools & Technologies
Microsoft OfficePharmacy Benefit Management Systems
Certifications & Qualifications
Pharmacy Technician License
Industry Keywords
MedicareMedi-CalHEDISCAHPSHIPAA
About the role
Key responsibilities & impact- Input, review and decision Medicare Part B and Medi-Cal requests for J codes, S code, Q codes, B codes and other medical benefits drugs/supplies
- Review requests based on UM logic and criteria including LCD, NCD, UM manual, MCG, MDX and other established criteria
- Perform technical/clinical review of authorizations involving drugs and utilization management, including authorization, chart notes and relevant clinical information
- Decide prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements
- Meet departmental goals including turnaround, production expectations and quality metrics
- Support company goals and IEHP’s strategic priorities
- Communicate with doctors and pharmacies regarding IEHP RxUM policies and procedures
- Interface with IEHP’s pharmacy benefit management company regarding adjudication and medication processing issues
- Assist with expedited discharge-related reviews and coordinate with specialty pharmacy providers and internal departments
- Assist the Clinical Pharmacist in reviewing members’ medication regimens and care coordination
- Participate in quality improvement enhancements, LEAN projects and managing for daily improvement
- Participate in pharmacy projects supporting HEDIS and CAHPS standards
- Participate in team training and professional development related to prior authorization processing, pharmacy claims, grievances, discharges and pharmacy issues
- Perform other duties required for successful health plan operations
- Ensure privacy and security of protected health information in accordance with HIPAA policies and procedures
Requirements
What you’ll need- One (1) or more years of experience as a pharmacy technician in a pharmacy required
- Experience in a pharmacy benefit management setting preferred
- High School Diploma or GED required
- Possession of an active, unrestricted, and unencumbered Pharmacy Technician license issued by the California State Board of Pharmacy required
- Knowledge in pharmaceutical terminology is required
- Excellent organizational, written, and verbal communication required
- Typing speed of 40 corrected words per minute (CWPM) required
- Microsoft Office; Microsoft Excel skills preferred
- Good interpersonal skills
- Excellent critical thinking skills
- Schedule may adjust based on business need which may include evenings, holidays, and weekends
- Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval
- May be required to report to IEHP’s main campus periodically for mandatory in-person meetings or other business needs
- Must occasionally lift or move up to 25 pounds
Benefits
Comp & perks- Competitive salary
- Hybrid schedule
- CalPERS retirement
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance