The Pharmacy Services Specialist 1 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. 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.
ESSENTIAL FUNCTIONS OF THE ROLE
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.
Coordinates the evaluation and entry of criteria and prior authorizations with pharmacy clinical and benefits teams.
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.
Verifies eligibility information on all inquiries and updates as appropriate while following HIPAA standards and guidelines set forth by pharmacy processes to include concerns regarding coordination of benefits (COB).
Meets performance measurement goals set by the pharmacy department to comply with department and regulatory standards.
Performs claim tests in the pharmacy claims processor system and reports findings to appropriate departments.
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.
Assists with reviewing and auditing reports as determined by management.
Conducts quality control activities to ensure level of excellence on service standards.
KEY SUCCESS FACTORS
Certified Pharmacy Technician (CPhT) preferred.
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.
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
- EDUCATION - H.S. Diploma/GED Equivalent
- EXPERIENCE - 1 Year of Experience