This position is responsible for serving as a subject matter expert and primary information resource in either the Commercial or Government Programs books of business for questions and issues identified within Clinical Review (CR). This position will lead the Clinical Review team by performing ongoing quality audits, leadership support, identifying and implementing process/performance improvement initiatives.
• Maintain expert knowledge of Commercial/Government Programs line of business and serve as a technical resource for questions involving benefits, claims and process. Work daily with CR staff to assist in resolving complex issues.
• Provide input to the maintenance and ongoing development of CR’s audit program to support client satisfaction and visibility. Document audit expectations and grading methodology. Update regularly as information changes.
• Perform ongoing quality audits for new and tenured employees. Provide performance feedback and trend analysis to identify areas of improvement.
• Assist in client and program implementations, including technical documentation of new processes and employee education through audit feedback.
• Ensures compliance with SLA requirements and standard operating procedures including HIPAA/CMS/URAQ/NCQA regulations.
• Assist in gathering and documenting requirements for new systems and future enhancements. Lead in departmental end-user testing. Act as a liaison between business and IS for related issues.
• Serve as a liaison for directing unresolved issues to the appropriate representatives in Care Management, Pharmacy Operations, Benefit Design, Eligibility, Account Teams, or Claims for further evaluation and resolution.
• Participates in the communication of clinical information within the department. Creates new reference materials in the absence of documentation.
• Collaborates with the Clinical Review Trainers to provide feedback for training modules and documentation.
• Creates customized QA reports for various internal and external customers.
• Assumes some leadership responsibilities in the absence of the Clinical Review management team.
• Other duties as assigned
• Minimum of 1 year experience as a Clinical Review Technician , meeting expected performance in quality audits and productivity standards • Pharmacy technician certification from an accredited certification testing facility
• Strong system aptitude, demonstrated proficiency in use of RxCLAIM, Lotus, Excel, Word • Demonstrated proficiency in the benefit design and review process for multiple clients • Excellent verbal, written, presentation, and problem-solving skills • Demonstrated organizational, analytical, interpretive and time-management skills. • Business judgment and interpersonal maturity. Must be self-motivated and able to work with minimal supervision. Ability to make consistent and unbiased decisions. • Strong interpersonal skills: ability to mentor in a positive, patient manner, recognizing unique personality types and learning style preferences • Previous leadership, training or audit experience • Ability to professionally handle sensitive and confidential information.
Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.
If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.
We are proud to be an Equal Opportunity/Affirmative Action Employer M/F/D/V. We maintain a drug-free and tobacco-free workplace and perform pre-employment substance abuse testing.