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Las Vegas, Nevada, United States
Onsite
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Provides physician and member support for LucyRx while also processing prior authorization requests in a timely manner and according to high quality standards.
Role and Responsibilities
Clinical Call center team member receives calls from Physician and member and provides the requested information or support while ensuring the privacy and security of PHI (Protected Health Information) as outlined in LucyRx’s policies and procedures relating to HIPAA compliance.
Understands the pharmacy benefit plans and accurately interprets the plan information to Physician and members.
Technical review of authorizations (drug and utilization management) that includes reviewing authorization, chart notes, and/or relevant clinical information to render a clinical recommendation and documents all actions in ticketing system.
Respond to prior authorization requests within compliance turnaround times and meeting quality standards regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
Ensure that all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
Communicate with providers (prescriber and pharmacy) on issues related to formulary, non-formulary criteria, or respective policies and procedures.
Generates letters to members communicating PA outcomes, or if lack of response.
Manages the monthly medication prior authorization renewal process.
Interface with LucyRx’s adjudication system, when necessary, in regard to adjudication and medication processing issues.
Assist Clinical Pharmacist in review of Member’s medication regimen and assist in care coordination internally with Utilization Management, Behavioral Health, or Care Management departments.
Actively participate in internal quality improvement process enhancements.
Cross department support.
Participate in team training and professional development of prior authorization processing, pharmacy claims, grievances, discharges, and any related pharmacy issues.
Attendance and punctuality are essential functions for this position.
Other duties as assigned.
Qualifications and Education Requirements
Knowledge and Skills Required
Preferences
PHYSICAL REQUIREMENTS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
This is a largely sedentary role; however, some standing, walking, bending, and reaching may be required. Regularly operates in an office or home office setting which involves utilizing a computer, mouse, keyboard, and occasionally operates other standard office equipment, such as printer, copier, phone. Travel may be required by either car or airplane, or a combination of multiple modes of transportation.
LucyRx is an independent, next-generation pharmacy benefit manager (PBM) redefining prescription care. Fueled by innovation and decades of leadership experience, LucyRx delivers better outcomes through its integrated specialty network, formulary marketplace, and next-day home delivery solutions.
Powered by its proprietary AI platform, LucyIQ™, the company provides real-time insights that support evidence-based clinical decisions, clear pricing, and exceptional service from U.S.-based pharmacy technicians. Partnering with more than 60,000 pharmacies, LucyRx serves over 1,200 clients nationwide.
Salary 20.75 - 30.42 USD Hourly
