Pharmacy Benefit Specialist

Pharmacy Benefit Specialist I page is loaded## Pharmacy Benefit Specialist Iremote type:
Remote locations:
Remote Oregon time type:
Full time posted on:
Posted 3 Days Agojob requisition :
JR100717

Pharmacy Benefit Specialist I---------------------------------------------------------------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 and claims processing, as well as assistance with prior authorizations, formulary exceptions, appeals, grievances, and projects.
** Estimated Hiring Range:**$20.51 - $25.06
** Bonus Target:
** Bonus - SIP Target, 5% Annual Current Care Oregon Employees:
Please use the internal Workday site to submit an application for this job.

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** 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 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.

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.

Appeals and Grievances
* Explain pharmacy appeal and grievances provisions and process to members, providers and Care Oregon staff.
* Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances.

Project Coordination
* Minimal project participation.###
** Experience and/or Education
** Required* 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.

Preferred:
* Pharmacy Technician experience## ## Knowledge,

Skills and Abilities

Required Knowledge
* General understanding of managed care, Medicare, and Oregon Health Plan concepts

Skills and Abilities

* Proficient with Microsoft Office Products and general computer literacy
* Familiarity with medical and pharmaceutical terminology
* Ability to learn and effectively navigate Care Oregon 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…