Job description
Who We Are:
SmithRx is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service. With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.
We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:
- Integrity: Always operate with honesty and transparency so we earn the trust of our clients.
- Courage: Demonstrate the courage needed to take on a broken industry and continuously improve what we offer to optimize health outcomes.
- Together: Foster a collaborative and inclusive environment that values teamwork, respect, and open communication, and encourages creativity and diversity of thought.
Job Summary:
This is a 6 month contract position where you will assist members, providers, pharmacies, and the internal SmithRx teams to navigate complexities of prescriptions to guide timely coverage of clinically appropriate, cost effective medication therapy in accordance with plan benefit design and clinical criteria for coverage. This may involve coordination of clinical review cases, checking coverage and plan rules, verification of submitted information, pharmacy and provider outreach, review of prior authorization requests within established protocols, and assisting to triage and troubleshoot questions and escalations. At SmithRx, we design customized benefit plans for our customers and you are at the forefront of helping navigate and execute drug access.
What will you do:
- Verify eligibility and drug coverage under the plan benefit design to determine appropriate claims processing
- Responsible for triaging the process of clinical review for prior authorization requests at different levels as per established protocols
- Review prior authorization and similar requests under protocol using prior authorization criteria, claims history and plan benefit rules, including prescriber/pharmacy outreach to verify and gather complete required information
- Organize and prioritize multiple requests internally and externally to ensure timely prior authorization case management.
- Build and adjust authorizations under protocol within the claim adjudication system
- Use pharmacy technician experience to navigate drug products, formulations, and perform basic calculations to check and monitor accurate claims adjudication.
- Ability to critically assess and synthesize multiple workflows together in order to make a sound clinical decision
- Work across teams to coordinate outreach, address questions/escalations, and help guide processes and protocols for timely and appropriate medication coverage.
- Evaluate member clinical situation against medication policies and make a determination to approve or triage to Pharmacist for denial
- Critically assess when medications need to be sent for internal or external review based on synthesizing multiple protocols together
- Reach out to select external stakeholders for approval on drugs with dollar limits
What will you bring to SmithRx:
- High School diploma or GED or equivalent work experience
- Active Pharmacy Technician license required
- 2-5 years of experience as a Pharmacy Technician
- 1+ years of experience in prior authorization review (specifically working on the approval side at a PBM or health plan) required
- Proficiency in Mac, MS Office, G-Suite required
- Critical thinking to navigate complex customized benefit plans to make sound clinical decisions
- Active listening, conversational speaking skills, with a high degree of empathy
- Self-starter with ability to multitask, prioritize and manage time effectively
- Ability to communicate clearly, present complex information to members, clients, pharmacies, providers, and other teams internally
- Ability to work accurately within protocols and follow appropriate escalation pathways for unique situations or where clarification is needed.
