AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.
AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.
AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.
These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.
The primary responsibility of this position is to facilitate all aspects of the Prior Authorization/Coverage Determination process, manages the Pharmacy help desk line, assist Customer Service on drug-related concerns/issues for the AlohaCare QUEST Integrated (QI) and Advantage Plus (ACAP) Plans, and provides administrative support for formulary management and compliance related functions of the AlohaCare Pharmacy Department.
Primary Duties and Responsibilities:
Process all prior authorization (PA)/coverage determination (CD) and Direct Member Reimbursement (DMR) requests into the Prior Authorization (PA) System in an accurately and timely manner.
Adhere to turnaround times (TAT) for PAs/CDs and MDR as required the State, NCQA, and the CMS.
Assist members, pharmacies, prescribers, and internal staff with pharmacy claims processing, pharmacy benefits, and AlohaCare’s Formularies
Review and process daily rejected claim and monitoring of claims processing for potential Fraud, Waste, and Abuse (FWA) potential
Assists the Clinical Pharmacists with Medication Therapy Management (MTM)
Process member ‘‘lock-in”
Remain in compliance with the department’s policies and procedures
Other duties as assigned
Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
High school degree required or GED equivalent
Two (2) years of experience in Pharmacy
Nationally Certified Pharmacy Technician (CPhT)
Ability to type 45 words per minute (WPM)
Proficiency with Microsoft Word, Excel, and Outlook
Ability to effectively communicate verbal/written and work as a team member with all associates in a professional and business manner
Must be customer service oriented and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills
Strong organizational, prioritization, communications, and mathematics skills
Time management, leadership and organizational skills
Strong desire to assist people
Preferred Competencies and Qualifications:
College Degree in related field preferred
Pharmacy Technician experience at a managed care organization (MCO) or Pharmacy Benefits Manager (PBM)
Excellent communication skills (written and verbal)
Health care data system experience
Understand the principles of managed care pharmacy
Pharmacy claims processing computer system experience
Thorough knowledge of the principals and protocols of the medication prior authorization process and managed care pharmacy experience and/or retail pharmacy experience of not less than two years
Proficiency with Microsoft Word, Excel, and Outlook
Additional Job Requirements:
Learn and develop experience in the use of AlohaCare’s information system, QMACS, and AlohaCare’s historical data bases
Learn and develop experience in the use of Express Scripts Client website and various reporting tools as well as the claims and authorization processing platform/system sponsored by the PBM.
Mental, Physical and Environmental Demands:
Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
Ability to communicate via telephone and within a group
Requires operation of general office equipment to include PC
Requires access to own transportation if needed to attend off-site meetings.
Requires verbal and written communication in English with members and providers
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.