Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs: Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STARHealth Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more. Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY Under the direction of the Director of Pharmacy Analytics, functions as a Pharmacy Program Specialist in the Pharmacy Analytics department. Provides efficient and accurate responses to external customers (physicians, office staff, pharmacy providers, members, and brokers), and internal team members. Resolves outpatient pharmacy benefit coverage and prescription claim problems.
Communicates drug formulary guidelines, including drug formulary alternatives, prior authorization criteria, and group/member eligibility problems. JOB SPECIFICATIONS AND CORE COMPETENCIES Assist with processing medication prior authorization and appeal requests within required turn-around time. Monitor and process medication override requests-Communicate authorization and medication approval to Pharmacy Benefit Manager within required turn-around time.
Answer questions regarding pharmacy benefit and coverage of medical injectables under medical benefit. Resolve coverage issues with Pharmacy Benefit Manager pertaining covered drugs, copays, medication prior authorization requests and medication appeals. Make outreach to members and providers as directed to improve medication adherence.
Assist with generating reports and perform monitoring over delegated PBM functions as directed. Make outreach to members and providers as directed to resolve issues with medical requests within required turn-around time. Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plan, and other duties as assigned.
Education/Specialized Training/Licensure: HS Diploma or GED Registered with the Texas State Board of Pharmacy as a pharmacy technician and in good standing (CPhT) required. Bachelor's degree preferred. Work Experience (Years and Area): 1 year in related functions required.
Minimum of 1 year experience with a health plan or PBM preferred. Software Proficiencies: Microsoft Office