Using established criteria and guidelines, the pharmacy technician receives and processes priorauthorization requests made by providers and members for medications not inherently covered on amember's prescription drug plan.Resolve issues and complaints in a timely manner.Performs other duties as assigned by management.Handles inbound phone requests and gathers member data to provide information appeals.

Determining eligibility and screening incoming pharmacy prior authorization requests for all requireddocumentsPreparing, organizing, and distributing pharmacy prior authorization requests for review by pharmacist/physician and responding to pharmacist/physician requests for additional informationLearning and using Oscar and vendor tools to create, process, and properly track pharmacy priorauthorization requestsCollecting relevant medical information (via telephone, fax, and portal) and applying the appropriatePA criteriaMeeting required decision-making timeframes, including promptly triggering escalation for casesrequiring pharmacist review Clearly documenting all communication and decision-making, ensuringa peer could easily reference and understand your decision. Communicating oral and written priorauthorization outcome notifications that comply with standards and requirements for timeliness, contentand accuracy. Demonstrating the highest level of professionalism, accountability, and service in yourinteractions with Oscar teammates, customer service, providers, and members. Participating in qualityimprovement activities as requested. Developing a working familiarity with applicable regulatory andaccreditation requirements. Providing support on regulatory audits and quality accreditation surveys, asneeded. Supporting the team prepare for expansion into new markets, as needed. Acute attention todetail. Willingness to grow, learn, and work as a member of a cross-functional team.

Responsibilities include evaluating & authorizing approval of prior authorization pharmacy requests fromprescribers received by telephone and/or fax using client criteria. Primary duties may include, but notlimited to:Determines appropriateness for medications. Communicates decision to physicians, physician`s officestaff, medical management staff and/or pharmacists.Research, resolves, and documents prior authorization outcomes in pharmacy system.Communicates selected prior authorization criteria, pharmacy benefit coverage and formularyalternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.Escalates requests to Pharmacist when request requires extensive clinical review or denial.Research, resolves, and documents physician or client inquiries and grievances and provides verbal orwritten results to client, prescriber, provider and/or management.Verifies member information and inputs data for the pharmacists.Educates members on pharmacy-based rules related to prescriptions and medication resources orassistance programs.Processes prior authorization requests from physicians’ offices and ensures compliance with Medicarerequirements; informs relevant parties of all prior authorization determinations.Provides resolution to grievances and appeals issues.Maintains record keeping of prior authorizations, rebates, and monthly reports.

Performs duties involved in all facets of outpatient medication distribution which includes use of automation for prescription filling and mailing. Assists veterans with processing of medication refill requests, address changes, and missing medications. Stores and documents medication waiting for destruction. Uses technology to review the status of medications being processed, location of completed medications, and must possess knowledge of automated devices to assist with troubleshooting and problems. Compounds and/or reconstitutes oral and external non-sterile medications not otherwise available from manufacturers in a safe and effective manner. Operates and maintains pharmacy automation daily during times of heavy workload. Responsible for stock replenishment of automated dispensing cabinets assigned to the Outpatient Pharmacy. Submitted documents for Prior Authorizations. Troubleshoot insurance issues, working with Tricare to resolve. Educate patients regarding health care benefits.*Job ended due to COVID *

Assist in the development and/or revision of clinical application systems and lesson plans.Provide lesson plans, course outlines, and classroom materials to support both on AHLTA and CHCS applications. Also train on other various clinical applications. Utilize a variety of instructional technologies (e.g. audiovisual equipment, computer assisted instruction, etc.), training equipment(e.g. computer workstations). Maintain records of training, consulting, and troubleshooting activities; developing statistical reports as needed.Knowledge of health care environment for the delivery of classroom instruction on clinical information systems. Basic understanding of automated data processing concepts necessary in order to communicate with system users and identify changes in the system or hospital clinical environment that may affect training.Knowledge of educational techniques and training methodologies for delivery of classroom instruction using clinically related software applications.Knowledge of electronic health system applications such as MHS GENESIS, Cerner, Joint Legacy Viewer (LV), military legacy systems such as AHLTA or other commercial electronic health record systems. Knowledge of The Joint Commission (TJC) guidelines, recommendations, and patient safety goals. Basic understanding of clinical business process flow used within clinical settings to train where clinical documentation supports such initiatives.

Working with military personnel filling medications. Travel to outlining clinics to help when needed. Use CHCS, GSL, and Pk2 programs daily. Practice HIPAA daily. Check for drug interactions when filling medications. Process medical claims and followed up on Prior authorization to ensure they were approved. Experience in various healthcare programs to include Tricare and experience of regulations. Experience of processing claims. Educate patients on their Tricare benefits.Troubleshoot any rejections with Tricare. Worked closely to resolve any issues.Knowledge of standardized principles, practices, and applied techniques of various health care programs, policies and regulations and comprehensive health care delivery systems related to benefits, entitlements, and reimbursement which affect the entitlements of the beneficiary population. Knowledge of pertinent rules, regulations, policies, and components of Government healthcare programs, specifically DoD and TRICARE, and their interrelationships. Extensive experience of claims processing procedures and processes for resolving disputed claims. Knowledge of medical terminology and medical records sufficient to evaluate the extent of customer's knowledge of options and choices open to them. Ability to use and maintain a high degree of empathy, tact, and diplomacy when advising customers and dealing with sensitive patient issues Ability to communicate effectively. Processed prior authorizations.