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UPMC Rx Partners is looking for a full time Pharmacy Clinical Review Specialist to join their dedicated team!

This position provides prescription data entry and adjudication of claims under the supervision of a licensed pharmacist. This position provides customer service to Rx Partners Skilled nursing and Hospice clients. The clinical review specialist at Rx Partners works hand in hand with a licensed pharmacist to ensure medication deliveries are entered timely for each delivery while ensuring payment.

This role will work rotating daylight shifts, Monday through Friday, as well as one Saturday every 6th week.

UPMC offers a generous benefits package, an expansive total rewards package, opportunity to grow your career and much more. Apply today!

Responsibilities:

+ Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.

+ Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.

+ Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.

+ Perform prescription data entry under the supervision of a licensed pharmacist

+ Maintain or exceed designated quality and production standards.

+ Interface with other departments and identify medical documentation in support of prior authorization requests.

+ Act as a conduit of information between the Pharmacy, operations and clinical and the facility staff.

+ Report and respond to escalate issues and concerns in a within twenty-four hours.

+ Subject matter expert on prescription data entry requirements/timeframes according to line of business

+ HS diploma or equivalent required

+ 2 years of pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.

+ Experience in pharmacy claims process operating system required.

+ Excellent knowledge in retail pharmacy processes and LTC Pharmacy billing functions preferred.

+ Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management required

+ Thorough knowledge in MS Office and PC skills required.

+ Customer Service experience with communication via telephone, e-mail and face to face required.

+ Knowledge of electronic claims adjudication and resolution required

+ Experience with prioritizing and multitasking requiredLicensure, Certifications, and Clearances:Certified Pharmacy Technician preferredUPMC is an Equal Opportunity Employer/Disability/Veteran