Hiring for a Pharmacy Operations Specialist for a healthcare facility in Charlestown, MA
Experience:
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
Retail pharmacy with working drug knowledge is ok; payer background preferred.
Pay rate: $30/hr
M-F 8 hour days 40 hours/week
Job Summary:
Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the company’s pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed.
Key Functions/Responsibilities:
? 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
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Supervision Exercised:?None
Supervision Received:?General supervision received daily
Qualifications:
Education:
? Minimum of a High School diploma or equivalent required. Associate or Bachelor?s degree 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
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