Career Opportunities: Pharmacy Benefit Specialist II (24256)Requisition ID 24256 - Posted 05/17/2024 - CareOregon - Full Time - Permanent - Portland - Multi Location (16)
Job Description Print PreviewCandidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.Job Title
Pharmacy Benefit Specialist II
Exemption Status
Non-Exempt
Department
Pharmacy
Manager Title
Pharmacy Benefit Operations Supervisor
Direct Reports
n/a
Requisition #
24256
Pay and Benefits
Estimated hiring range $45,850 - $55,500 / year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits
Posting Notes
This is a fully remote role, but you must reside in one of the listed 9 states. You are required to work Pacific Standard Time.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
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 and 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 and 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 and reconsiderations, gather data and documentation and prepare appeals For full info follow application link.We are an equal opportunity employer. We evaluate qualified applicants without regard to race, color, r
eligion, sex, national origin, disability, veteran status, and other protected characteristics. The EEO is the Law poster is available here.