Works in collaboration with the Director, Clinical Service Center to execute day-to-day operational needs, including clinical review of rejected claims, recommending clinically appropriate covered alternative medication, overseeing the processing of Automatic Therapeutic Interchange (ATI) recommendations and meeting the requirements of the Clinical Service Center. Adheres to the company’s quality and customer service standards, policies and procedures, and state and federal guidelines in the LTC pharmacy to ensure quality production, work flow and achieving operational goals and objectives.
- Responsible for oversight clinical claim reject activity
- making appropriate clinically comparable, formulary alternative recommendations
- review approve clinical documentation associated with prior authorization submissions
- Provides CSC technicians instructions regarding actions to be taken when working with insurance plans and internal / external customers to take steps toward rejected claims resolution
- Works in conjunction with other LTC departments ensuring achieving daily volume, quality and service goals
- Communicates with customers, insurance companies and internal pharmacy staff to effectively and appropriately resolve rejected clinical claims
- Maintains organized record of CSC documentation related to ATI or claims management
- Applies superior customer service skills when working with both internal and external customers
- Works in collaboration with the CSC Technicians and Director to meet department goals and objectives.
- Provides assistance in the development, deployment and management of department and customer supported initiatives
- Assists with ensuring safety practices and procedures are adhered to and practiced.
- Enforces all company and departmental policies and procedures.
- Complies with all applicable state and federal regulations related to pharmacy practices.
- Customer Focus - Is dedicated to meeting the expectations and requirements of internal and external customers; gets first-hand customer information and uses it for improvements in products and services; talks and acts with customers in mind; establishes and maintains effective relationships with customers and gains their trust and respect.
- Perform related duties and special projects as required or assigned.
- Participates in special projects to identify and implement operational improvements. Ability to work with others in a positive productive manner anticipates and responds to the positions areas of responsibilities. Contribute to a positive work environment and overall team effort.
- Actively contributes to the evaluation and continuous improvement of LTC pharmacy services, policies and procedures.
- Other duties as assigned or directed.