Pharmacy Benefit Specialist Jobs

Status: Direct Hire

Job Title: Pharmacy Benefit Specialist

Location: 100% Remote

Salary: $40,000 - $45,000

About the company:

We're a nonprofit providing health insurance services to meet the healthcare needs of low-income Oregonians. We serve about one-quarter of Oregon Health Plan members.

Our mission is to inspire and partner to create quality and equity in individual and community health. Our vision is healthy communities for all individuals, regardless of income or social factors.

We focus on the total health of our members, not just traditional health care. In teaming up with members, families, and communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.

Every day, we help hundreds of thousands of Oregonians get the care they deserve. But good health is more than health care. That’s why we invest in programs that help people get housing, healthy food, job training, and more.

Pharmacy Benefits Specialist:

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. Core responsibilities include customer service and claims processing, as well as assistance with prior authorizations, formulary exceptions, appeals, grievances, and projects.

Pharmacy Benefits Specialist I Responsibilities

Customer Service and Claims Processing:

• Educate members, providers, pharmacies, and staff about the formularies and pharmacy benefit policies.
• Maintain confidentiality within HIPAA regulations and function on “need to know” principles.
• Respond to drug coverage inquiries in an accurate and timely manner to members, members’ representatives, providers, and staff.
• Communicate in a professional and respectful manner.
• 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.
• Document all customer service activities according to organization requirements.
• 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:

• Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances.
• Sort incoming faxes and distribute them according to assignments.
• Review member’s medication and eligibility history, load authorization in claim adjudication platform(s).
• Appeals and Grievances:
• Prior Authorizations (PA) and Formulary Exceptions
• Explain pharmacy appeal and grievances provisions and processes to members, providers, and staff.
• Verify member’s plan eligibility and applicable benefit for drug coverage.
• Perform data entry into the claims processing system, document management systems, databases, and spreadsheets as assigned.
• Assist members and providers with the PA, formulary exception, and coverage determination process.
• Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers, or pharmacies, letters & mailings, and reports.
• Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception, and coverage determinations requests. Notify members, providers, or provider staff of prior authorization and formulary exception decisions.
• Maintain files according to unit protocols.

Organizational Responsibilities:

• 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.
• 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.

Pharmacy Benefits Specialist I Qualification:

Minimum 1-year work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 1-year experience in a health insurance plan

Knowledge, Skills, and Abilities Required:

General understanding of managed care, Medicare, and Oregon Health Plan concepts.

Skills and Abilities:

• Ability to tolerate and manage stress.
• Growing ability to network and utilize internal and external resources.
• Results and service-oriented.
• Ability to learn and effectively navigate PBM software programs necessary to perform job responsibilities.
• Ability to learn new skills and abilities.
• Familiarity with medical and pharmaceutical terminology
• Ability to follow policies and procedures in performing job responsibilities.
• Effective listening, verbal, and written communication skills.
• Ability to exercise professionalism.
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions.
• Ability to accept managerial direction and feedback.
• Ability to focus on and comprehend information.
• Proficient with Microsoft Office Products and general computer literacy
• Ability to assess a situation and use critical thinking skills and company resources to determine a solution.
• Ability to hear and speak clearly for at least 3-6 hours/day.
• Ability to organize, plan, and prioritize daily workflow within time constraints.
• Ability to accept direction and feedback, as well as tolerate and manage stress.
• Ability to be flexible and adaptable.
• Ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours/day.
• Ability to work in an environment with diverse individuals and groups.