Nov 16, 2019
WellCare Health Plans Performs case processing, clinical evaluation and completion of coverage determinations from receipt to adjudication. Utilizes clinical knowledge and resources to evaluate and assess the clinical necessity of the coverage determination. Technician assignments will be broad in nature across DER, Injectables, Appeals and/or Direct Member Reimbursement (DMR). Essential Functions: Reviews medical records against prior authorization criteria and decision tools and recommends a coverage determination decision on approvals and/or denials on various drug products. Verifies eligibility, timeliness and record completeness of coverage determination cases and follows up with the provider as necessary Communicates with Pharmacists and Medical Directors, providing updates on the case disposition of coverage determinations. Researches and documents the clinical aspects of the case and the reasoning for the coverage determination outcome in numerous databases. When appropriate, seeks additional clinical advice and recommendations to properly adjudicate the coverage determination case. Electronically enters claim detail information in internal organization applications, PBM applications and documents receipt, disposition and other noteworthy aspects of the cases in these applications. Initiates and continues direct communication with health care providers (Pharmacist, Physicians, and Nurses) involved with the care of the member to obtain complete and accurate information for coverage determination. Ensures timely processing and review of coverage determinations to meet departmental goals and state/federal specific benchmarks for timeliness. Documents data input and output accurately to ensure compliance with data integrity for CMS Universes and corporate compliance directives. Ensures that services provided to eligible members are within benefit plan and appropriate medications are being utilized. (i.e.: determining if medication Part D eligible and the 4 brand limit.) Assists with implementation of healthcare initiatives and specific strategies that improve the quality and outcomes of care in market. Responds to requests from member service and other issues. Performs additional projects as assigned. Additional Responsibilities: Candidate Education: Required A High School or GED Candidate Experience: Required 1 year of experience in pharmacy operations managed care, hospitals and/or retail environments Preferred 1 year of experience in managed care pharmacy and/or appeals/grievances Required 3 years of experience in If position is in NC, minimum of three (3) years of pharmacy benefits call center experience. Candidate Skills: Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Demonstrated written communication skills Intermediate Ability to effectively present information and respond to questions from families, members, and providers Intermediate Ability to work independently Beginner Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Intermediate Other Ability to use pharmaceutical references Beginner Other Ability to evaluate information from both oral and written sources, pharmaceutical references and report information to pharmacists Intermediate Other Working knowledge of prescription medications and pharmacotherapy Licenses and Certifications: A license in one of the following is required: Preferred Certified Pharmacy Technician (CPhT) Required Other If position is in NC, Certified Pharmacy Technician registered with the NC Board of Pharmacy Technical Skills: Required Intermediate Microsoft Word Required Intermediate Microsoft Excel Required Intermediate Microsoft Outlook Required Beginner Healthcare Management Systems (Generic) Languages: About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.
Professional Diversity Network Detroit, MI, USA Full-Time