Primary Location: Phoenix, AZ Additional Locations: AZ-Phoenix, TX-Houston Apply
Description: Supports comprehensive coordination of Medicaid and/or Medicare pharmacy services including intake and processing of pharmacy authorization requests. Promotes and supports quality effectiveness of healthcare and Pharmacy Services. Evaluates, authorizes approval, and communicates decisions for pharmacy requests according to clinical guidelines.
High volume call center and production unit.
Evaluates and authorizes approval of pharmacy requests received by telephone, facsimile, and/or other means using client clinical criteria. Determines appropriateness for medications. Communicates decision to physicians, physician’s office staff, medical management staff, members, and/or pharmacists.
May perform clinical research to support request.
Utilizes various proprietary systems to build, research, process and enter requests.
Performs non-medical research including eligibility verification, COB, and benefits verification.
Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Escalates requests to Pharmacist when request requires extensive clinical review or denial.
Promotes communication, both internally and externally, to enhance effectiveness of medication therapy management services.
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
May communicate with Aetna Case Managers and Health Plan staff.
Process requests in compliance with various laws and CMS regulations and company policies and procedures.
Sedentary work involving significant periods of sitting, talking, hearing, and keying.
Work requires visual acuity to perform close inspection of written and computer-generated documents as well as dual PC monitors.
PTCB certification and Arizona and/or Texas State License, current and in good standing, are required.
Experience in retail, hospital, facility or call center is preferred.
Proficiency in computerized pharmacy systems and software applications.
Excellent verbal and written communication skills.
Experience with Windows-based software applications.
High School Diploma or G.E.D.
Clinical Licensure: Pharmacy Technician Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
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