Job Description

Job 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.
-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, physicians office staff, medical management staff, members, and/or pharmacists.
-Will perform clinical research to support request.
-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.
-Process requests in compliance with various laws and CMS regulations and company policies and procedures.
-May communicate with Aetna Case Managers, Health Plan Staff, External Pharmacies and Health Care Providers
-Promotes communication, both internally and externally, to enhance effectiveness of medication therapy management services.
-Sedentary work involving significant periods of sitting, talking, hearing, and keying.
-Escalates requests to Pharmacist when request requires extensive clinical review or denial.

Required Qualifications
-Proficiency in computerized pharmacy systems and software applications.
-Excellent verbal and written communication skills.
-Experience with Windows-based software applications.
-National Pharmacy Technician certification and Arizona and/or Texas State License, current and in good standing, are required.
-Utilizes various proprietary systems to build, research, process and enter requests.
-Protects the confidentiality of member information and adheres to company policies regarding confidentiality.

Preferred Qualifications
-High volume call center and production unit.
-Experience in retail, hospital, facility or call center is preferred.

Education
High School diploma, G.E.D.

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.