Job Id: 61639
Pharmacy Benefit Specialist II
This position is responsible for working with members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. This is an advanced level support position, requiring Pharmacy Technician Certification. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation.
This is a hybrid position. Onsite expectations- Around 1 day per week or a few days per month. Based on the needs of the business.
Pharmacy Benefit Specialist II Responsibilities:
Customer Service and Claims Processing:
Communicate in a professional and respectful manner.
Maintain confidentiality within HIPAA regulations and function on “need to know” principles.
Respond to drug coverage inquires in an accurate and timely manner to members, members’ representatives, providers, and the staff.
Educate members, providers, pharmacies, and the staff about the formularies and pharmacy benefit policies.
Document all customer service activities according to organization requirements.
Follow policies and procedures to answer questions from members, providers and staff regarding claims processing as it pertains to the pharmacy benefits and coverage of drugs under the major medical benefit.
Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other staff for assistance.
Data Entry and Clerical Support:
Sort incoming faxes and distribute according to assignments.
Maintain files according to unit protocols.
Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.
Prior Authorizations (PA) and Formulary Exceptions:
Verify member’s plan eligibility and applicable benefit for drug coverage.
Review member’s medication and eligibility history, load authorization in claim adjudication platform(s).
Assist members and providers with the PA, formulary exception and coverage determination process.
Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions.
Perform prior authorization reviews with pharmacist oversight.
Appeals and Grievances:
Explain pharmacy appeal and grievances provisions and process to members, providers and staff.
Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by Pharmacists & Medical Directors.
Complete pharmacy appeals and notify members and providers of outcome.
Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.
Under the supervision of a pharmacist and/or the operations supervisor, assist with pharmacy benefit projects including, but not limited to process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach.
Perform work in alignment with the organization’s mission, vision and values.
Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
Strive to meet annual business goals in support of the organization’s strategic goals.
Adhere to the organization’s policies, procedures, and other relevant compliance needs.
Perform other duties as needed.
Pharmacy Benefit Specialist II Qualifications:
Minimum 2 years work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 2 years’ experience in a health insurance plan.
Minimum 1 year experience with managed care and/or pharmacy benefit management.
Knowledge, Skills and Abilities Required:
Advanced knowledge of medical and pharmaceutical terminology.
Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Skills and Abilities:
Proficient with Microsoft Office Products and general computer literacy.
Ability to learn and effectively navigate the company and PBM software programs necessary to perform job responsibilities.
Ability to follow and provide input into policies and procedures in performing job responsibilities.
Advanced listening, verbal, and written communication skills
Ability to exercise professionalism.
Proficient ability to network and utilize internal and external resources.
Ability to focus on and comprehend information.
Ability to learn new skills and abilities.
Ability to assess a situation and seek or determine appropriate resolution.
Ability to accept managerial direction and feedback.
Ability to tolerate and manage stress.
Results and service oriented.
Ability to be flexible and adaptable.
Ability to organize, plan, and prioritize daily workflow and projects within time constraints.
Ability to work in an environment with diverse individuals and groups.
Ability to work independently with minimal supervision.
Ability to learn, focus, understand, and evaluate information and determine appropriate actions.
Ability to accept direction and feedback, as well as tolerate and manage stress.
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day.
Ability to hear and speak clearly for at least 3-6 hours/day.
Salary: $44,580k-$53,940k/yr. (DOE)
Our client is thrilled to offer benefit eligible employees a competitive and robust total rewards package that includes comprehensive benefit offerings. Company benefits are designed to provide employees and their families with a range of options to meet and support their personalized needs.
VanderHouwen is an award-winning, Women-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen has been successfully placing experienced professionals throughout the Pacific Northwest and nationwide. Our recruitment teams are highly specialized in either Technology and IT, Engineering, or Accounting and Finance career markets. Our recruiters value building meaningful, professional relationships with each candidate as well as developing honed knowledge of companies' staffing needs and workplaces. Partner with us to land your next exciting career.
VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state or federal civil rights laws.
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