Pharmacist

·        Reviews physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.  Forwards initial denials to appropriate queue for further review.  Generates notification letters to members and physicians on approved and denied requests.

·        Handles calls and correspondence from providers; responds to inquiries, complaints and reconsiderations.  Documents calls in inquiry tracking system.  Using established protocols ensures resolutions provided are presented in a clear and accurate manner.  Receives escalated calls that cannot be clinically resolved by 1st level intervention.  Researches, resolves and responds to provider clinical inquiries.

·        Supports Fraud and Abuse program system oversight.  Communicates any suspected fraud discovered by the contact center staff.  Recommends course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards.

·        Serves as second-line contact for all internal pharmacy related issues.  Functions as clinical liaison between internal staff and pharmacy network participants.  Ensures internal changes that may affect network services are reflected in the claims processing system.

·        Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review.  Works with appropriate individuals/vendors to facilitate compliance.  Responds to and drafts correspondence to physicians regarding requests on Drug Formulary.  Responds to telephone inquiries from physicians, other healthcare professionals and members regarding select drug information.

·        Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services.  Makes recommendations on program improvements, based on findings and utilization.  Assures compliance to PerformRx policies and procedures regarding pharmacy protocol.