It's fun to work in a company where people truly BELIEVE in what they're doing! We're committed to bringing passion and customer focus to the business. MMM Holdings, LLC Job Description BUSINESS UNIT: MMM Holdings, LLC DEPARTMENT: Pharmacy Services POSITION: Pharmacy Clinical Representative POSITION DESCRIPTION Serves as primary liaison between MMM Health Care/PMC Medicare Choice, Government Health Plan (Vital) and any other additional benefit managed by the pharmacy department such as OTC, PAM, MTM, etc. beneficiaries and providers, for the purpose of Member/Providers service, education, issues resolution, coverage determination requests and customer satisfaction. RESPONSIBILITIES Handles daily pharmacy coverage determination requests as established in the Coverage Determination Requests (CDR’s), PA/Exceptions Policies and Procedures ASES and CMS guidelines. Manage telephone calls from pharmacy and providers in a timely and courteous manner. Assist pharmacies in the claims payment process. May educate the provider, beneficiary or the pharmacy and if required, will perform benefit overrides based on the drug utilization criteria/protocol as defined by ASES, CMS or exception process. Reviews the Coverage Determination Request (CDR’s) according with the established guidelines approved by MMM/PMC ,Medicare, MMMultihealth/PMC (“MUMH/PMCG”) within pre-determined timelines established by CMS/ASES. Document the CDR’s with complete follow-up history in the Pharmacy Application and Prescription Benefit Manager (PBM) claims processing system. Provide all relevant clinical information of a CDR to the Clinical Pharmacist for evaluation. Communicate verbally and/or by writing the results of the coverage determination request following CMS requirements to the members and prescribing physicians. Perform system overrides (e.g., prior authorization) on the PBM claims processing system to ensure that the claims will be correctly adjudicated. Maintain an understanding of the clinical guidelines of MMM/PMC.and MMMultihealth/PMC (“MUMG/PMCG”). Assist in the training of pharmacy technician staff and others as required. Performs any other job related duties as assigned by the Supervisor. General knowledge of Prior authorization criteria and pharmacy claims processing. Provide support to additional programs within the pharmacy department which could include but is not limited to coordination of care, data entry, claim review, coordination of orders, call center tasks, outbound outreach to providers and beneficiaries, identification of gaps in care, etc. EDUCATION AND EXPERIENCE Puerto Rico Board of Pharmacy Technician Certification. Minimum one year experience in a healthcare environment. Evidence of good communication, interpersonal and problem‑solving skills. General knowledge of prior authorization criteria and pharmacy claims processing. GENERAL ABILITIES AND KNOWLEDGE General knowledge of Prior authorization criteria and pharmacy claims processing. 2. Strong interpersonal skills. Experience with pharmacy payment systems and/or claims. General knowledge of drugs. Strong customer focus. Professional telephone etiquette. 7. Independent and a self-starter. 8. Effective verbal communication with plan members and providers. Basic computer skills. Must be able to function with frequent interruptions, accept change and be able to prioritize tasks efficiently when faced with competing demands. 11. Able to work flexible schedules including night shifts, weekends, and holidays. 12. Ability to understand the importance of and respect the confidentiality of all member information. 13. Time Management Skills: establishing priorities and accomplishing tasks in a timely manner. 14. Team Work: ability to work in a team environment to create solutions to problems. LANGUAGE SKILLS Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers. MATHEMATICAL SKILLS Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. REASONING ABILITY Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. PHYSICAL AND MENTAL DEMANDS Working on computer and telephone for long periods of time; ability to effectively utilize office telephone equipment; repetitive motion using fingers and forearms in data entry, manual dexterity to access filing system, use fax and copy machines. This position requires that weight be lifted or force be exerted up to 10 pounds. ENVIROMENT AND WORKING CONDITIONS Normal office environment. The noise is typically moderate. This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve. If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!