Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

Under the direction of the Supervisor, Pharmacy Utilization Management, the Pharmacy Utilization Management (UM) Specialist is responsible for setting up, reviewing, and processing prior authorization cases in the various applications for coverage determination requests. The specialist ensures timely disposition of reviews for established timeframes.

Key Responsibilities/Duties – what you will be doing

Key Responsibilities/Duties – what you will be doing (top five):

Performs full case set up from fax, ePA, phone and email prior authorization requests
Upon case set up, a full case review is performed ensuring all applicable regulatory and accreditation requirements and turnaround times are met
Documents all relevant case notes for PAs (prior authorizations) requiring additional review by a pharmacist or medical director
The Pharmacy Utilization Management Specialist will run test claims for approved authorizations and reach out to members and providers as necessary
Communicates with providers via department phone queue to process phone PAs and resolve provider inquiries
Additional tasks include performing daily quality checks to ensure compliance, managing the Pharmacy UM team email box, responding to provider inquiries, managing electronic prior authorization (ePA) requests, submitting process improvements, among others
Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Director
Other duties and projects as assigned.

Qualifications – what you need to perform the job

Qualifications – what you need to perform the job

Education, Certification and Licensure

High School Diploma or GED
Associate's degree in Healthcare, Nursing, or a related area or equivalent experience
Certified Pharmacy Technician (CPhT)

Experience (minimum years required):

Minimum of 3 years of pharmacy experience, preferably in managed care/PBM setting
Software/Database experience - RxClaims, PAHub, CAS, or MHK is preferred

Skill Requirements

Proficient in MS Office - Excel, Word, and PowerPoint Preferred
Ability to prioritize work when processing pharmacy PA requests per guidelines and within specific turnaround times
Ability to process high volumes of requests with great accuracy
Attention to detail and the ability to handle multiple demands, as well as balance multiple priorities in a fast-paced environment
Good working knowledge of medical terminology
Must be able to work independently, and as part of a team. Regular interface with various levels of staff and management is required.
Must be able to exercise appropriate judgement as necessary, following all rules and regulations where required

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

Must be able to work under normal office conditions and work from home as required.
Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
May be required to work additional hours beyond standard work schedule.
Travel required on an as needed basis. Some early mornings, evenings, weekends, or extended workday may be required as program dictates. Must have flexibility with work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

Medical, dental and vision coverage
Retirement plans
Paid time off
Employer-paid life and disability insurance with additional buy-up coverage options
Tuition program
Well-being benefits
Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org