shop Services Lead - Government Programs | Portland, OR

less experienced shop Technicians and provides higher level Prior Authorization expertise. Participates on the shop Tech team to assists the Clinical shop Consultants and shop Services staff with formulary-related operations and other operational processes which require knowledge and experience with medicals.

Responsibilities: Acts as the team lead; plans and assigns work for team of shop Technicians and provides on the job coaching to less experienced team members Handles more complex Prior Authorization issues and assists with more difficult cases. Performs all duties as described in this document unless doing so would require clinical judgment. In any situation in which clinical judgment

is necessary, the shop Services Technician Lead will seek assistance from appropriate medical personnel. Appropriate medical personnel will be available for support during normal business hours.

Responds to non-clinical shop issues from providers, shop services staff, case managers, pre-authorization nurses, ENCC personnel, and government programs personnel and customer service. These shop issues include formulary drug coverage, appeal and reconsideration claim status, and pricing for drug claims. Completes daily formulary operational processes, including tracking, processing, and obtaining appropriate documentation for shop medical exception requests, prior authorization requests, reconsideration's,

and appeals. Prepares reconsideration requests for Clinical shop Consultants review by obtaining and organizing appropriate documentation, including, but not limited to medical chart notes/reports and medication profiles.

Communicates (orally and by written documentation) information and determinations to providers and members as necessary. Obtains and organizes drug utilization data, including patient specific and population based data, in a manner which facilitates clinical review and decisions by Clinical Pharmacist Consultants. Organizing data includes but is not limited to sorting drugs into appropriate therapeutic and generic categories.

Assists with auditing and investigations of medication-related claims, cases, and providers to identify misuse of medications, misuse of Regence Health Plan resources, substance abuse, and erroneous and fraudulent billing practices. Investigates and organizes workflow for claims referred to shop Services for review and allowable determination (misc. J codes, providers on review, reconsideration's). Supports wellness and disease state management programs for shop Service and corporately which contribute to NCQA accreditation and ongoing quality improvement. Contributes to and supports the corporation's quality initiatives through process improvement teams and by encouraging team and individual contributions toward the corporation's quality improvement efforts.

Conducts business in compliance with company's Code of Business Conduct, immediately reports violations of the code to management, human resources, internal audit, legal of the compliance officer; and helps in investigating alleged wrongdoing. Provides guidance and on the job coaching to less experienced shop Technicians. Minimum Requirements: Demonstrated expert knowledge of Medical terminology and practices including but not limited to: medical products, including orals, injectables, infusion products, and chemotherapy.

Health care coding systems such as ICD9, CPT, and HCPCS. General office practices and procedures. Grammar and techniques of business practice. HIPAA regulations Demonstrated ability to lead a team of shop technicians, including assigning day to day work, providing practical training and providing informal human capital leadership support. Demonstrated ability to interact effectively with a variety of health care professionals, including physicians, nurses, pharmacists, and billing staff both internally and externally.

Demonstrated maturity, tact, diplomacy, and persuasiveness. Ability to perform medical pricing calculations. Ability to type 45 words per minute with 95% accuracy. Demonstrated ability to use MS Office products and other corporate software and other business machines as required. Demonstrated broad understanding of the processes and procedures for all areas within the shop Tech Team. Ability to organize, plan, and prioritize daily workflow and projects within time constraints including ability to lead and mentor team members in addition to managing own work load. Demonstrated experience with health insurance and/or prescription benefits.

Normally to be proficient in the competencies listed above: The shop Services Technician Lead would have a high school diploma or equivalent and a minimum of six or more years of experience as a shop technician in a retail, hospital, or other licensed shop setting and some demonstrable leadership experience or equivalent combination of education and experience in a related field. Pharm Tech Certification may be substituted for 2 years of experience. Bachelor's degree in general education or related field preferred. #LI-remote Work Environment: No unusual working conditions.

Work primarily performed in office environment. May be required to work overtime. Associated topics: antibody, biomedical, clinical, cytometry, diet, disease, drug, nutritionist, transfection, trauma