|Date Posted||April 1, 2018|
The position utilizes specialized pharmacy knowledge and expertise to assist participating pharmacies, members, providers, CalOptima departments, health networks, and other entities in assuring the efficient, timely and effective provision of pharmaceutical products and services to CalOptima members. The incumbent interacts with other staff throughout the organization, as well as external contacts on a daily basis. The incumbent is responsible for ongoing public contacts including, but are not limited to, members, individual pharmacies, member advocates, family members, health networks, Public Guardian’s Office, Regional Center, and other agencies. The incumbent is authorized to make and carry out decisions on behalf of the Pharmacy Department within established policies and procedures.
- Maintain documentation of Medication Therapy Management (MTM) program activities in various systems such as Guiding Care, MTM Vendor software, and Facets.
- Conduct outbound calls to MTM eligible members in accordance with MTM program desktops.
- Maintain documentation of member and pharmacy cases in Facets and manage case load to ensure cases are resolved within departmental standards as needed.
- Function efficiently and productively in the pharmacy call center as needed.
- Using a pharmacy computer program, retrieve drug-specific technical data and information necessary for the completion of departmental and interdepartmental pharmacy-related functions and operations.
- Coordinate resolution of provider and member pharmacy issues requiring specialized technical and professional knowledge and expertise, including pharmacy authorizations.
- Resolve claims disputes between providing pharmacies, the pharmacy claims administrator, CalOptima Claims Department, and other entities as necessary.
- Interpret and articulate Pharmacy Management program policies and procedures to pharmacy providers, other providers, other CalOptima staff, external agencies and others as required.
- Assist in the processing of pharmaceutical prior authorization and appeals requests as per the CalOptima Prior Authorization Guidelines as needed.
- Establish and maintain key contacts both internally and externally to assure appropriate coordination and provision of pharmacy services to CalOptima Members.
- Accept referrals from Member Services and work in conjunction with employees from this department to resolve all pharmacy-related member complaints, including those related to the pharmacy authorization process.
- Assist pharmacies and health plans in resolving member-specific pharmacy services access issues, removing barriers to access to pharmaceutical services.
- Adhere to department policies and procedures.
- Other duties as assigned by management.