Pharmacy Benefit Specialist II

Pharmacy Benefit Specialist II

This position is responsible for working with Care Oregon 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 Care Oregon Employees:

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 Care Oregon staff. Educate members, providers, pharmacies, and Care Oregon staff about the Care Oregon 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 Care Oregon staff regarding claims processing as it pertains to the Care Oregon 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 Care Oregon staff for assistance.

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.

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.

Explain pharmacy appeal and grievances provisions and process to members, providers and Care Oregon staff. Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by Care Oregon 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.

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.

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

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