Job Description

Job Description

Job Description

Who We Are:

SmithRx is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service. With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.

We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:

• Integrity: Always operate with honesty and transparency so we earn the trust of our clients.
• Courage: Demonstrate the courage needed to take on a broken industry and continuously improve what we offer to optimize health outcomes.
• Together: Foster a collaborative and inclusive environment that values teamwork, respect, and open communication, and encourages creativity and diversity of thought.

Job Summary:

You will assist members, providers, pharmacies, and the internal SmithRx teams to navigate complexities of prescriptions to guide timely coverage of medication through our Connect savings programs. This may involve coordination of cases, checking coverage and plan rules, verification of submitted information, pharmacy and provider outreach, review of clinical information within established protocols, and assisting to triage and troubleshoot questions and escalations. At SmithRx, we design customized benefit plans and savings programs for our customers and you are at the forefront of helping navigate and execute drug access.

What you will do:

• Verify eligibility and drug coverage under the plan benefit design to determine appropriate claims processing
• Responsible for triaging the process of Connect program review for member cases, which may require clinical supports as per established protocols
• Review clinical requests under protocol using clinical policy criteria, claims history and plan benefit rules, including prescriber/pharmacy outreach to verify and gather complete required information
• Organize and prioritize multiple requests internally and externally to ensure timely prior authorization case management.
• Build and adjust authorizations under protocol within the claim adjudication system
• Use pharmacy technician experience to navigate drug products, formulations, and perform basic calculations to check and monitor accurate claims adjudication.
• Ability to critically assess and synthesize multiple workflows together in order to make a sound clinical decision
• Work across teams to coordinate outreach, address questions/escalations, and help guide processes and protocols for timely and appropriate medication coverage.
• Evaluate member clinical situation against medication policies and make a determination to approve or triage to Pharmacist for denial
• Complete overrides and other pertinent requests accurately and in a timely manner for Connect Department
• Conduct expedited reviews for patient assistance programs
• Build member prior authorizations appropriately and as required for Connect department
• Knowledge of or ability to navigate through use of Salesforce, Banjo, Confluence and other programs
• Perform drug review using pertinent sites for patient assistance such needymeds, and manufacturer's website
• Attend and contribute to weekly meetings

What you will bring to SmithRx:

• High School diploma or GED or equivalent work experience
• Active Pharmacy Technician license required
• 2-4 years of experience as a Pharmacy Technician
• 2+ years of experience in Pharmacy Benefit Management (PBM) is required, along with knowledge and expertise in resolving claim rejections
• 2+ years of experience in prior authorization review is preferred
• Proficiency in Mac, MS Office, G-Suite required
• Critical thinking to navigate complex customized benefit plans to make sound clinical decisions
• Active listening, conversational speaking skills, with a high degree of empathy
• Self-starter with ability to multitask, prioritize and manage time effectively
• Ability to communicate clearly, present complex information to members, clients, pharmacies, providers, and other teams internally
• Ability to work accurately within protocols and follow appropriate escalation pathways for unique situations or where clarification is needed.
• Flexibility and ability to adapt to changes and updates to processes and protocols
• Ability to work independently as well as part of an extended, cross-functional team to organize and prioritize multiple deadlines, define problems as they arise, and work through them
• Demonstrate problem-solving skills, information gathering, research, alternatives analysis, applying creative solutions to unique and/or immediate issues
• Demonstrate accurate drug product/dose calculations for appropriate claim adjudication and knowledge of general pharmacy and drug product information for the prescription filling process

What SmithRx Offers You:

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&D Insurance
• 3 Weeks Paid Time Off
• 12 Paid Holidays
• Paid Parental Leave Benefits
• Flexible Spending Benefits
• 401(k) Retirement Savings Program
• Short-Term and Long-Term Disability
• Wellness Benefits
• Commuter Benefits
• Employee Assistance Program (EAP)
• Well-stocked Kitchen In Office Locations
• Professional Development and Training Opportunities

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