Healthcare Claims Review - Full-time / Part-time

Reviewing and Analyzing pharmacy claims using a multi-screen computer system.

Following/answering specific criteria to determine if a Pharmacy claim should be ACCEPTED or DENIED.

Processing, communicating, documenting and tracking of requests for formulary exceptions, prior authorization, quantity exceptions, and following processes for delegated utilization management (UM).

Will use multiple resources to research and look up answers in order to answer the series of criteria questions

The Clinical Review Pharmacy Technician is responsible for reviewing and processing Pharmacy Claims that have been rejected by a Patients Insurance company. The role entails researching, analyzing and verifying information to appropriately determine whether or not the claim should be approved or denied.

Background information:

1) Claim is rejected at the Pharmacy by the insurance company (insurance typically rejects for the following reasons)
* Step Therapy: When the patient has not tried a generic or alternative (cheaper) therapy and the Insurance company does not want to pay for the most expensive medication
* Formulary Exception: Each Patient's Insurance plan has a specific Preferred Formulary List (A list of medications that is covered). The insurance company will reject the medication being prescribed if it is not listed/covered on the Patient's insurance preferred list
* Quantity Limit: When the patient is being prescribe a quantity that exceeds what their insurance plan typically covers
2)The Pharmacy faxes a PRIOR AUTHORIZATION form to the Physician to fill out
3) The Physician sends the filled out PRIOR AUTHORIZATION form to the insurance company to review (IN THIS CASE PRIME)
4) This is the point that Clinical Review receives the request for review

Review criteria to determine if the request can be approved.
ï‚· Responsible for accurately entering Prior Authorizations in claims system to ensure appropriate claims will adjudicate
ï‚· Respond to completed requests by creating written communication of the clinical outcome to the member and the member's physician within client specific turnaround times
ï‚· Research and respond to calls and emails directed to the Clinical Review team
ï‚· Demonstrate proper use of documented resources, training materials, and various systems to complete requests
ï‚· Responsible for performing outreach to pharmacies and physician's offices related to the Clinical Review process across multiple clients to obtain all necessary information related to UM requests, including occasional member assistance
ï‚· Accountable to provide all relevant clinical information specific to a UM request to the Clinical Review Pharmacist and the Physician
ï‚· Managing work queue and volumes to meet client specific turnaround times
ï‚· Collaboration with team members, leads, and Pharmacists to promote consistency of review completion across the research team

About Aerotek:

Aerotek, headquartered in Hanover, Md., is a leading provider of technical, professional and industrial staffing services. Established in 1983, Aerotek is an operating company of Allegis Group, the largest provider of staffing services in the U.S. Aerotek operates a network of more than 200 non-franchised offices throughout the U.S., Canada and Europe. For more information, visit .

Aerotek is acting as an Employment Agency in relation to this vacancy.