Providence Health & Services Pharmacy Technician Quality Medical Management (Call Center) in Portland, Oregon
Providence St. Joseph Health is calling a Pharmacy Technician Quality Medical Management (Call Center) to our location in Beaverton, OR. This position may work remotely from a one hundred mile radius of Beaverton. In 2022 this role may pivot to a hybrid model working a combination of in office and remote.
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We are seeking a Pharmacy Technician - Quality Medical Management (Call Center) - who will be responsible for:
Coordination and performance of technically detailed pharmacy and benefit work affecting pharmacy and health plan operations, programs and information systems
Integrating technical pharmacy aspects with that of Medical Review, Case Management, Mental Health/Chemical Dependency, and Quality Management
Communicating directly with Providence Health Plan (PHP) Customer Service and PHP Members, PHP Network Pharmacies, and regulatory entities at the federal and state level
Communicating directly with pharmacists, nurses, physicians, and other health care providers and their staffs regarding medication management programs and initiatives
Defusing potential conflicts while facilitating and negotiating solutions during first contact communications while maintaining excellent customer service, strong pharmacy network relationships, and strong physician and prescriber relationships.
Functioning as a liaison and problem solver with multiple providers (physicians, pharmacists, office staff, hospital staff, member, and payor), or Plan departments.
Identifying and responding to requests for medical preauthorization which require immediate determination by a Clinical Reviewer or Clinical Pharmacy Coordinator/Pharmacist.
Managing multiple priorities and time deadlines efficiently and effectively through ability to work independently while be cognizant of team environment and areas requiring collaboration.
PHS goals and objectives while meeting the needs of the individual.
Patient Population Served: Neonate, Pediatric, Adolescent, Adult, Geriatric
- Consequently, the employee must be competent in the interpretation of a patient's self-report or behavior, and this information must be interpreted with an understanding of the cognitive, physical, emotional/psychosocial and chronological maturation process. The treatment of patients should be individualized and should reflect an understanding of the developmental needs and range of treatment needs for each patient.
In this position you will have the following responsibilities:
Coordinates and processes independently pharmacy prior authorizations taking into consideration pharmacy benefits, medication utilization policies, documented technician approval criteria, information submitted by prescriber, and age-related presentation of member requesting
Maintains pharmacy benefit member eligibility review process and database
Oversees point-of-service claims transactions processed on a daily basis through Argus Health System
Refers unusual occurrences to Argus Analyst/Coordinator
Takes, triages and documents incoming calls and requests
Identifies and obtains resources for those requiring immediate attention
Handles those appropriately through established protocols utilizing appropriate level of assessment and judgment
Routes work to other resources as deemed appropriate
Monitors, retrieves, and prioritizes incoming work as required
Performs intake and system data entry of information such as authorization and referral requests, patient information, discharge information, medication therapy management information, drug utilization management information
Uses sound judgment in identifying the need for clinical review or pharmacist/physician intervention by routing to appropriate licensed staff based on guidelines and established protocols/procedures
Maintains the accuracy and integrity of the database
Determines and assigns appropriate and correct coding such as length of service, level of care, diagnosis and procedure, and system identifiers
Identifies medical cases for review by using ICD-9 and CPT-4 coding systems
Provides technical assistance and coding support to Clinical Reviewers by using PAS, ICD and CPT coding systems to ensure accurate diagnosis and procedure codes.
Initiates information system search for needed documentation and information for cases and their review
Assists in the development and maintenance of loss reports
Notifies physicians and other prescribers of prior authorization and specific medication utilization issues, including communication of clinical status and documentation of such notification
Acts as department liaison and resource to members, Health Plan providers, and Health Plan departments to problem solve or address inquiries regarding work, workflow, processes, information system issues and relationships
Communicates with members, patients, network pharmacies and providers to obtain information, signatures and appropriate sign off in order to facilitate workflows
Develops written communications to prescribers and network pharmacies as directed
Audits processed pharmacy claims, system call documentation, and written correspondence for quality ensuring information is correct, complete, and clear
Communicates and serves as a resource to Customer Service, marketing staff, provider relations staff, pharmacies, physicians and others
Develops written communications such as frequently asked questions as needed
Trains and assists provider and office staff, members and payors, operations department and other Health Plan employees in UQM/RX processes and system usage as applicable
Serves as knowledge holder on pharmacy matters within the health plan and serves as a consultant as needed and within scope of position
Continuously monitors security and safety of medical records and medical information to protect confidentiality
Purges medical and other records as required according to established protocols
Reports statistical information on work unit activity
Collects and analyzes data and develops reports to indicate quality and effectiveness of work
Recommends and initiates change to ensure continuous quality improvement in work processes
Researches pended claims and authorizations or incomplete medical records and provides resolution or recommendations for solution
Identifies, notifies, documents and distributes information related pharmacy department work, and patient follow-ups, alerting the appropriate people as necessary
Authorizes payment of pharmacy claims and DMR's (direct member reimbursements) according to established departmental policies
Collects, organizes, reviews and verifies records submitted by prescribers and network pharmacies knowing that records are subject to both federal and state review and/or audit
Maintains sound working knowledge of all relevant policies and procedures. Develops written procedures for workflow processes
Required qualifications for this position include:
H.S. Diploma or GED; High school diploma or equivalent.
2 years' experience as a pharmacy technician in a managed care environment -OR- 3 years pharmacy technician experience in an outpatient pharmacy
National Certification as Pharmacy Technician within one year of employment.
Licensure in Oregon as a Pharmacy Technician upon hire.
Preferred qualifications for this position include:
- Bachelor's Degree.
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Pharmacy Technician
Other Location(s): Oregon-Portland, Washington, Oregon, Washington-Vancouver
Req ID: 323850