JOB DESCRIPTION
Job Summary
Molina Pharmacy Services/Management staff work to ensure that Molina members, providers, and pharmacies have access to all medically necessary prescription drugs and those drugs are used in a cost-effective, safe manner. These jobs are responsible for creating, operating, and monitoring Molina Health Plan's pharmacy benefit programs in accordance with all federal and state laws. Jobs in this family include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as, therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).
KNOWLEDGE/SKILLS/ABILITIES
- Handles and records inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.
- Provides coordination and processing of pharmacy prior authorization requests and/or appeals.
- Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.
- Assists with clerical services/tasks and other day-to-day operations as delegated.
- Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.
- Assists member and providers with initiating oral and written coverage determinations and appeals.
- Records calls accurately in call tracking system.
- Maintains specific quality and quantity standards.
JOB QUALIFICATIONS
Required Education
High School Diploma or GED equivalent
Required Experience
1-3 years of call center or customer service experience
Preferred Education
Associate degree
Preferred Experience
- 3-5 years; healthcare industry experience preferred
- National pharmacy technician certification
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
