JOB SUMMARY

The Pharmacy Services Specialist 2 communicates with members, providers and clients to discuss benefits of the Health Plan Pharmacy services, makes determinations and enters prior authorizations based on criteria met and resolves claims processing and eligibility issues while following department policies and procedures. This position works on the customer?s behalf, as well as, being a liaison of the Health Plan to find root cause issues to address concerns that are brought forward by the customer. Serves in a lead role, acting as a subject matter expert (SME) and trainer.

ESSENTIAL FUNCTIONS OF THE ROLE

Provides oversight and reporting on performance measure goals set by the pharmacy department to comply with department and regulatory standards.

Provides coaching and training to Pharmacy Services Specialist 1 staff in collaboration with the Call Center Manager. May assist with the selection of new pharmacy call center staff.

Researches and responds to formal customer complaints within established timelines to meet regulatory requirements.

Collects, reviews and reports on quality control activities for all Pharmacy Services Specialist 1 staff. Assists with reviewing and auditing reports as determined by management.

Establishes and maintains excellent working relationships with key operational personnel both internally and externally.

Guides and educates customers about the fundamentals of the benefit plan to maximize the value of their contract utilizing the Health Plan website for benefits, claims information and prior authorization process. Attends client?s employee health benefit fairs as a Health Plan Pharmacy representative to address questions and assist members in better understanding their pharmacy benefit.

Assists customers, by phone or through written correspondence, to satisfactorily solve claims processing issues for all Health Plan lines of business, utilizing the pharmacy claims processing system and all other appropriate departmental resources. Performs claim tests in the pharmacy claims processor system and reports findings to appropriate departments.

Coordinates the evaluation and entry of criteria and prior authorizations with pharmacy clinical and benefits teams. Documents requested appeals on behalf of the customer, escalates appropriately and responds to appeals pertaining to the pharmacy benefit.

Verifies and updates eligibility information on all inquiries while following HIPAA standards and guidelines set forth by pharmacy processes to include concerns regarding coordination of benefits (COB).

Researches and resolves complex issues and escalated cases across multiple databases to include outreach to pharmacies to reprocess claims that have been identified as having potential issues.










KEY SUCCESS FACTORS

Certified Pharmacy Technician (CPhT) preferred.

Ability to lead a team and provide direction.

Practices good phone etiquette and uses effective communication skills (both verbal and written).

Ability to document clearly and concisely to articulate findings.

Strong customer service skills.

Excellent interpersonal, listening and communication skills.

Ability to use & navigate multiple computer applications to research and address caller needs.

Excellent analytical, problem-solving skills and attention to detail.

Knowledge of prescription terminology and pharmacy practices and procedures preferred.

Ability to work independently, as well as, in a team environment.

Ability to work in a fast-paced environment while maintaining accuracy and performance standards.

Must be proficient in typing and basic computer skills, particularly Microsoft Word and Excel.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - H.S. Diploma/GED Equivalent

- EXPERIENCE - 3 Years of Experience