Pharmacy Benefit Specialist Ii

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, or Nevada.

Job Summary

This position is responsible for working with CareOregon 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.

Essential Responsibilities

Customer Service and Claims Processing

• Document all customer service activities according to organization requirements.
• Communicate in a professional and respectful manner.
• Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit.
• Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies.
• 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 CareOregon staff.
• Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance.

Data Entry and Clerical Support

• Sort incoming faxes and distribute according to assignments.
• Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.
• Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
• Maintain files according to unit protocols.

Prior Authorizations (PA) and Formulary Exceptions

• 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.
• Verify member’s plan eligibility and applicable benefit for drug coverage.
• Perform prior authorization reviews with pharmacist oversight.
• 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.

Appeals and Grievances

• Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
• Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.
• Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff.
• Complete pharmacy appeals and notify members and providers of outcome.

Project Coordination

• 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.

Organizational Responsibilities

• Perform other duties as needed.
• 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.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Strive to meet annual business goals in support of the organization’s strategic goals.
• Perform work in alignment with the organization’s mission, vision and values.

Experience and/or Education

Required

• 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

Knowledge

• Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts
• Advanced knowledge of medical and pharmaceutical terminology

Skills and Abilities

• Advanced listening, verbal, and written communication skills
• Ability to assess a situation and seek or determine appropriate resolution
• Ability to exercise professionalism
• Proficient ability to network and utilize internal and external resources
• Proficient with Microsoft Office Products and general computer literacy
• Ability to accept managerial direction and feedback
• Ability to tolerate and manage stress
• Ability to hear and speak clearly for at least 3-6 hours/day
• Results and service oriented
• Ability to work in an environment with diverse individuals and groups
• Ability to be flexible and adaptable
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• 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 focus on and comprehend information
• Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities
• Ability to organize, plan, and prioritize daily workflow and projects within time constraints
• Ability to work independently with minimal supervision
• Ability to learn new skills and abilities
• Ability to follow and provide input into policies and procedures in performing job responsibilities

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.