Pharmacy Benefit Specialist II

Pharmacy Benefit Specialist IIThis 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. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation. This is a M-F position. Estimated Hiring Range:
$25.92 - $31.68 Bonus Target:
Bonus - SIP Target, 5% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
Essential 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 CareOregon staff.

- Educate members, providers, pharmacies, and CareOregon staff about the CareOregon 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 CareOregon staff regarding claims processing as it pertains to the CareOregon 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 CareOregon 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 CareOregon staff.

- Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon 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.

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.

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

Preferred

- Pharmacy Technician Certification (CPhT)

- Pharmacy Technician experience

- Pharmacy related outbound calls experience

Knowledge, Skills and Abilities Required
Knowledge

- Advanced knowledge of medical and pharma