Providence St. Joseph Health is calling a Pharmacy Technician Quality Medical Management to our location in Beaverton, OR.
We are seeking a Pharmacy Technician Quality Medical Management to be responsible for coordination and performance of technically detailed pharmacy and benefit work affecting pharmacy and health plan operations, programs and information systems in the Pharmacy Services Department of the Quality Medical Management Division. Position includes integrating technical pharmacy aspects with that of Medical Review, Case Management, Mental Health/Chemical Dependency, and Quality Management. Technician responsibilities include communicating directly with Providence Health Plan (PHP) Customer Service and PHP Members, PHP Network Pharmacies, and regulatory entities at the federal and state level. The position also communicates directly with pharmacists, nurses, physicians, and other health care providers and their staffs regarding medication management programs and initiatives.
- Defusing potential conflicts while facilitating and negotiating solutions during first contact communications while maintaining excellent customer service, strong pharmacy network relationships, and strong physician and prescriber relationships.
- Functioning as a liaison and problem solver with multiple providers (physicians, pharmacists, office staff, hospital staff, member, and payor), or Plan departments.
- Identifying and responding to requests for medical preauthorization which require immediate determination by a Clinical Reviewer or Clinical Pharmacy Coordinator/Pharmacist.
- Managing multiple priorities and time deadlines efficiently and effectively through ability to work independently while be cognizant of team environment and areas requiring collaboration.
- Administering pharmacy benefits, pharmacy network contracts, and employer group contracts in a manner that achieves PHS goals and objectives while meeting the needs of the individual.
Patient Population Served: Neonate, Pediatric, Adolescent, Adult, Geriatric
Consequently, the employee must be competent in the interpretation of a patient's self-report or behavior, and this information must be interpreted with an understanding of the cognitive, physical, emotional/psychosocial and chronological maturation process. The treatment of patients should be individualized and should reflect an understanding of the developmental needs and range of treatment needs for each patient.
In this position you will have the following responsibilities:
- Coordinate and process independently pharmacy prior authorizations taking into consideration pharmacy benefits, medication utilization policies, documented technician approval criteria, information submitted by prescriber, and age-related presentation of member requesting.
- Maintain pharmacy benefit member eligibility review process and database. Oversees point-of-service claims transactions processed on a daily basis through Argus Health System. Refers unusual occurrences to Argus Analyst/Coordinator.
- Take, triage and document incoming calls and requests, identifies and obtains resource for those requiring immediate attention, handles those appropriate through established protocols utilizing appropriate level of assessment and judgment. Routes work to other resources as deemed appropriate. Monitors, retrieves, and prioritizes incoming work as required.
- Perform intake and system data entry of information such as authorization and referral requests, patient information, discharge information, medication therapy management information, drug utilization management information. Uses sound judgment in identifying the need for clinical review or pharmacist/physician intervention by routing to appropriate licensed staff based on guidelines and established protocols/procedures. Maintains the accuracy and integrity of the database.
- Determine and assign appropriate and correct coding such as length of service, level of care, diagnosis and procedure, and system identifiers. Identifies medical cases for review by using ICD-9 and CPT-4 coding systems.
- Provide technical assistance and coding support to Clinical Reviewers by using PAS, ICD and CPT coding systems to ensure accurate diagnosis and procedure codes.
- Initiate information system search for needed documentation and information for cases and their review. Assists in the development and maintenance of loss reports.
- Notify physicians and other prescribers of prior authorization and specific medication utilization issues, including communication of clinical status and documentation of such notification.
- Act as department liaison and resource to members, Health Plan providers, and Health Plan departments to problem solve or address inquiries regarding work, workflow, processes, information system issues and relationships.
- Communicate with members, patients, network pharmacies and providers to obtain information, signatures and appropriate sign off in order to facilitate workflows. Develops written communications to prescribers and network pharmacies as directed.
- Audit processed pharmacy claims, system call documentation, and written correspondence for quality ensuring information is correct, complete, and clear.
- Communicate and serve as a resource to Customer Service, marketing staff, provider relations staff, pharmacies, physicians and others. Develops written communications such as frequently asked questions as needed.
- Train and assist provider and office staff, members and payors, operations department and other Health Plan employees in UQM/RX processes and system usage as applicable. Serves as knowledge holder on pharmacy matters within the health plan and serves as a consultant as needed and within scope of position.
- Continuously monitor security and safety of medical records and medical information to protect confidentiality. Purges medical and other records as required according to established protocols.
- Report statistical information on work unit activity. Collects and analyzes data and develops reports to indicate quality and effectiveness of work. Recommends and initiates change to ensure continuous quality improvement in work processes.
- Research pended claims and authorizations or incomplete medical records and provides resolution or recommendations for solution.
- Identify, notify, document and distribute information related pharmacy department work, and patient follow-ups, alerting the appropriate people as necessary.
- Authorize payment of pharmacy claims and DMR's (direct member reimbursements) according to established departmental policies.
- Collect, organize, review and verify records submitted by prescribers and network pharmacies knowing that records are subject to both federal and state review and/or audit.
- Maintain sound working knowledge of all relevant policies and procedures. Develop written procedures for workflow processes.
Required qualifications for this position include :
- National Certification as Pharmacy Technician within one year of employment
- Licensure in Oregon as a Pharmacy Technician upon hire
- 2 years experience as a pharmacy technician in a managed care environment, OR 3 years pharmacy technician experience in an outpatient pharmacy
Preferred qualifications for this position include:
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple.
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Pharmacy Technician
Req ID: 299362