Duties & Responsibilities:

• 95% - Program Support
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Handles specified caseloads to ensure cases are resolved within departmental standards and maintains documentation of member and pharmacy cases.
  • Retrieves drug-specific technical data and information necessary to complete departmental and interdepartmental pharmacy-related functions and operations.
  • Assists network pharmacies and prescribers with the resolution of pharmacy-related issues such as billing, claims processing, eligibility or pharmacy authorization requests.
  • Resolves claims disputes between network pharmacies, pharmacy claims administrator, CalOptima Health’s Claims department and other entities as necessary.
  • Interprets and articulates Pharmacy Management program policies and procedures to pharmacy providers, other providers, CalOptima Health staff, external agencies and others as needed.
  • Assists in processing pharmaceutical prior authorization and appeals requests per the CalOptima Health prior authorization guidelines.
  • Establishes and maintains key contacts internally and externally to assure appropriate coordination and provision of pharmacy services to CalOptima Health members.
  • Processes referrals from and works in conjunction with the Customer Service department to resolve all pharmacy-related member complaints and prior authorization requests. 
• 5% - Other
  • Completes other projects and duties as assigned. 

Minimum Qualifications:

• High school diploma or equivalent PLUS 1 year of experience as a Pharmacy Technician in the ambulatory, community, home infusion, long-term care or managed care setting required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications:

• Associate’s degree in a health-related field.
• Pharmacy Technician Certification Board (PTCB) credentials.
• Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Required Licensure / Certifications:

• Completion of an accredited Pharmacy Technician training program and possession of a registration certificate as a Pharmacy Technician from the California Board of Pharmacy required.

Knowledge & Abilities:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.  
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. 
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.