CAREOREGON, INC.
Pharmacy Benefit Specialist II
CAREOREGON, INC., Salt Lake City, Utah, United States, 84193
CAREOREGON, INC. Pharmacy Benefit Specialist II
Location: Salt Lake City, UtahRequisition ID: 24529 - Posted: 09/11/2024 - CareOregon - Full Time - PermanentCandidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.Job Title:
Pharmacy Benefit Specialist IIExemption Status:
Non-ExemptDepartment:
PharmacyManager Title:
Pharmacy Benefit Operations SupervisorDirect Reports:
n/aRequisition #:
24529Pay and Benefits:
Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits.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 inquiries accurately and timely 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.Resolve 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 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.Facilitate a resolution for prior authorization, formulary exception, and coverage determinations requests.Notify members and providers 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 review by CareOregon Pharmacists.
We are an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, national origin, disability, veteran status, and other protected characteristics. The EEO is the Law poster is available here.
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Location: Salt Lake City, UtahRequisition ID: 24529 - Posted: 09/11/2024 - CareOregon - Full Time - PermanentCandidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.Job Title:
Pharmacy Benefit Specialist IIExemption Status:
Non-ExemptDepartment:
PharmacyManager Title:
Pharmacy Benefit Operations SupervisorDirect Reports:
n/aRequisition #:
24529Pay and Benefits:
Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits.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 inquiries accurately and timely 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.Resolve 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 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.Facilitate a resolution for prior authorization, formulary exception, and coverage determinations requests.Notify members and providers 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 review by CareOregon Pharmacists.
We are an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, national origin, disability, veteran status, and other protected characteristics. The EEO is the Law poster is available here.
#J-18808-Ljbffr