Job type full-time remote
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Full job description
Reporting to the manager of pharmacy operations, the pharmacy operations specialist is primarily responsible for supporting the bmchp pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external partiesIn addition, the operations specialist will support the day-to-day operations of the pharmacy program as needed.
Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements
Properly apply clinical policy criteria to the review of prior authorization requests
Review and interpret member’s eligibility, claim history, and pharmacy program information using the pbm claims software to provide information to both internal and external clients via telephone or email
Interprets medical and pharmacy data and accurately enters information into system according to regulatory and ncqa accreditation requirements
Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications
Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
Provide pharmacy-related customer service to both internal and external parties.
Process pharmacy authorizations utilizing pbm real time online claims adjudication software
Support new clinical program implementation
Serve as a liaison to member services and other internal clients for real-time support on pharmacy benefit interpretation, pharmacy policy interpretation, and plan design interpretation.
Other responsibilities as needed
Minimum of a high school diploma or equivalent requiredAssociate or bachelor’s degree preferred
Two or more years of experience in a professional or pharmacy setting
Previous experience in a managed care environment preferred
Prior customer service experience preferred
Competencies, skills, and attributes:
Excellent customer service skills
Prior experience assisting members and/or providers with telephone inquiries
Strong organizational, problem solving, communication, and interpersonal skills
Excellent written and oral communication skills required.
Must have strong data entry and attention to detail in building cases
Must be able to multitask and be results oriented
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Posted 4 days ago
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