Pharmacy Benefit Specialist I

Role Overview

• 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 inquiries 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 determination requests
• Notify members, providers or providers staff of prior authorization and formulary exception decisions
• Appeals and Grievances
• Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff
• Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances
• Project Coordination
• Minimal project participation

Requirements

• 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
• Pharmacy Technician experience preferred
• General understanding of managed care, Medicare, and Oregon Health Plan concepts
• Proficient with Microsoft Office Products and general computer literacy
• Familiarity with medical and pharmaceutical terminology
• Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities.
• Ability to follow policies and procedures in performing job responsibilities
• Effective listening, verbal, and written communication skills
• Ability to exercise professionalism
• Growing 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 use critical thinking skills and company resources to determine a solution
• 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 within time constraints
• Ability to work in an environment with diverse individuals and groups
• 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

Benefits

• medical, dental, vision, life, AD&D, and disability insurance
• health savings account
• flexible spending account(s)
• lifestyle spending account
• employee assistance program
• wellness program
• discounts
• multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings)
• strong retirement plan with employer contributions
• PTO and Paid State Sick Time based on hours worked/scheduled hours
• paid holidays, volunteer time, jury duty, bereavement leave