Pharmacy Customer Service Assistant II Job Bloomington area,Minnesota USA,Healthcare

Health Partners is hiring a Pharmacy Customer Service Assistant. The Pharmacy Customer Service Assistant II reviews requests for medical policy or prescription drugs that require a coverage determination. This is primarily a pharmacy customer service position that serves as a resource to providers, members, member service staff, pharmacies, and department staff with regard to pharmacy benefits, pharmacy claims, formulary, and pharmacy policy and procedures.

Physician and member requests are processed independently by reviewing requests based on pre-determined clinical criteria. This position also reviews and determines appropriate reimbursements/processing of all claims requested from members and providers. This position applies all accountabilities below to all of Health Partners products including Fully Insured, Self-Insured, Medicare, and Medicaid.

QUALIFICATIONS REQUIRED

High School diploma or GED
Three years recent Pharmacy Technician experience in a pharmacy that includes familiarity with pharmacy benefits, pharmacy claims, and working with difficult customers in person and via telephone; or three years Prior Authorization and pharmacy benefit experience at a pharmacy benefit company or health plan outside of Health Partners/GHI.
Six-months computer experience including pharmacy systems
Pharmacy Technician certification (CPhT)
Broad knowledge of drugs and drug categories
Broad knowledge of pharmacy benefits
Demonstrated independent analytic problem solving skills
Excellent written and oral communication skills
Demonstrated ability to convey information to others in a clear, concise, and courteous manner by phone, direct contact, and in writing
Ability to make decision based on established protocols. Ability to deal effectively with varying workloads, stress levels and tight deadlines
Ability to work independently and establish work priorities in an environment with frequent interruptions
Ability to maintain productive working relationships with team members and other internal and external customers with exceptional customer service skills
Ability to work independently and make appropriate decision following corporate guidelines with the ability to research and fully document internal practices or problems that contribute to customer dissatisfaction in order to reduce future complaints and errors.
Exceptional organizational skills

PREFERRED

Completion of Pharmacy Tech program
Certified Pharmacy Technician (CPhT) Certification
Knowledge of Health Partners and Health Partners Pharmacy Administration department

PHYSICAL REQUIREMENTS

This position requires the use of close, visual perception and normal manual dexterity. Incumbent must be able to sit for prolonged periods of time. Must be able to speak, read and write English fluently.

ACCOUNTABILITIES

Key contact for expedited, urgent, and complex benefit and pharmacy issues including coverage determination, benefit design, and claims. Interpret unique and complex benefits.

Organize, retrieve, and share member information under tight timelines in accordance with state and federal policies including but not limited to National Council Quality Assurance, ERISA, and CMS (Centers for Medicare and Medicaid Services)

Process requests using HIPAA security measures.

Assist in internal and external audits.

Identify and interpret Explanation of Benefits received from members and other carriers.

Provide excellent customer service to providers, members, member services staff, internal and external staff, and pharmacies regarding pharmacy benefits and claims, formulary, and pharmacy policy and procedures for all Health Partners products (i.e. Fully Insured, Self-Insured, Medicare, and Medicaid). Focus on ownership and first call resolution. Evaluate and redirect calls to appropriate areas or departments.

Correspond with Medicare members, Member Services, Sales, brokers, Membership Accounting, clinics, pharmacies, and other departments regarding coverage determinations and pharmacy benefits. Independently process a high volume of coverage determination requests within established guidelines and based on pre-determined clinical criteria.

Research and triage pharmacy claims…