GENERAL SUMMARY:

Responsible for handling of daily pharmacy duties such as drug claim adjudication issues, prior authorization, and pharmacy benefit inquiries from members/patients, physicians, pharmacies, and other internal and external individuals. Subject matter

expert in the resolution of pharmacy benefit coverage issues and coordinating prior authorization and exception processes.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

Health Plan Based

1. Process and research requests for prior authorizations and other requested exceptions.

2. Perform quality assurance checks on claim adjudication for compliance/oversight.

3. Troubleshoot and resolve drug claim issues for patients, physicians, pharmacies, and internal staff.

4. Work with vendors such as pharmacies, other mail order facilities, claims processors, etc. to resolve issues and improve processes.

5. Assist or Administer pharmacy benefit designs for contracted health plans and/or pharmacies (i.e. Health Alliance Plan/Pharmacy Advantage).

6. Act as a resource for pharmacy benefit questions.

7. Produce and maintain assigned databases, reports, logs, summaries, and other documents as needed.

8. Perform additional related duties as assigned or necessary.

Pharmacy/Clinic Based

1. Act as a central resource to manage and monitor prior authorization and its validity prior to fill and provide a reason if prior authorization is denied.

2. Relays all communications to patients and providers regarding authorization outcome.

3. Proactively renews prior authorization in timely manner to provide continuity of care.

4. Proactively research and secure financial assistance for all patients.

5. Interpret patient treatment plans and medical notes for purposes of facilitating authorization requests.

6. Evaluate & communicate with nursing and physician staff any additional requirements or potential barriers to the treatment plan.

7. Act as a resource to assist with education of new hires.

8. Create and maintain patient/member information in applicable systems.

9. Work independently and exercise sound judgment in interactions with physicians, payors, and patients and their families.

10.Perform additional related duties as assigned and necessary.

EDUCATION/EXPERIENCE REQUIRED:

 High school diploma or G.E.D. equivalent. Associates degree preferred.

 A minimum of one year of previous pharmacy experience required.

 State of Michigan Pharmacy Technician Licensure preferred.

 Strong understanding and knowledge of medical/clinical and pharmacy terminology.

 Working knowledge of personal computers, and business software such as Microsoft Office.

 Organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and job duties/responsibilities.

 Strong interpersonal communication skills and experience with interacting with customers.

Additional Information

• Organization: Community Care Services

• Department: Pharmacy-Utilization Mgmt

• Shift: Day Job

• Union Code: Not Applicable

  Additional Details

  This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

Benefits

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.