CareOregon
Pharmacy Benefit Specialist II
CareOregon, Portland, Oregon, United States, 97204
Location field must contain 'city, state' or a zip code to perform a radius search (e.g., Denver, CO or 46122). City and state must be separated by a comma followed by a space (e.g., Houston, TX).Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.Job Title
Pharmacy Benefit Operations SupervisorExemption Status
Non-ExemptDepartment
PharmacyRequisition #
24529Pay and Benefits
Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits.
View benefitsPosting Notes
This is a fully remote role, but you must reside in one of the listed 9 states.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.Responsibilities
Customer Service and Claims Processing:
Communicate in a professional and respectful manner, maintain confidentiality within HIPAA regulations, respond to drug coverage inquiries, educate members and providers, document all customer service activities, and resolve pharmacy claims adjudication issues.Data Entry and Clerical Support:
Sort incoming faxes, maintain files, perform data entry, and assist with pharmacy projects.Prior Authorizations (PA) and Formulary Exceptions:
Verify member’s plan eligibility, review medication histories, assist with PA processes, and notify stakeholders of decisions.Appeals and Grievances:
Explain provisions to members, perform intake of appeals, and assist with processing pharmacy benefit appeals.Project Coordination:
Assist with pharmacy benefit projects and process improvements under supervision.Organizational Responsibilities:
Perform work in alignment with the organization’s mission, support equity and diversity, meet business goals, and adhere to policies.Experience and/or Education Required
Minimum 2 years work experience on a pharmacy team or in a health insurance plan.Minimum 1 year experience with managed care and/or pharmacy benefit management.Knowledge, Skills, and Abilities Required
Advanced knowledge of medical and pharmaceutical terminology.Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.Proficient with Microsoft Office Products and general computer literacy.Ability to learn and effectively navigate CareOregon and PBM software programs.Advanced listening, verbal, and written communication skills.Ability to work independently with minimal supervision and manage stress.Ability to organize, plan, and prioritize daily workflow and projects.Working Conditions
Work Environment(s): Indoor/OfficeTravel: May include occasional required or optional travel outside of the workplace.Candidates of color and veterans are strongly encouraged to apply. CareOregon is an equal opportunity employer and considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status. Visa sponsorship is not available at this time.
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Pharmacy Benefit Operations SupervisorExemption Status
Non-ExemptDepartment
PharmacyRequisition #
24529Pay and Benefits
Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits.
View benefitsPosting Notes
This is a fully remote role, but you must reside in one of the listed 9 states.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.Responsibilities
Customer Service and Claims Processing:
Communicate in a professional and respectful manner, maintain confidentiality within HIPAA regulations, respond to drug coverage inquiries, educate members and providers, document all customer service activities, and resolve pharmacy claims adjudication issues.Data Entry and Clerical Support:
Sort incoming faxes, maintain files, perform data entry, and assist with pharmacy projects.Prior Authorizations (PA) and Formulary Exceptions:
Verify member’s plan eligibility, review medication histories, assist with PA processes, and notify stakeholders of decisions.Appeals and Grievances:
Explain provisions to members, perform intake of appeals, and assist with processing pharmacy benefit appeals.Project Coordination:
Assist with pharmacy benefit projects and process improvements under supervision.Organizational Responsibilities:
Perform work in alignment with the organization’s mission, support equity and diversity, meet business goals, and adhere to policies.Experience and/or Education Required
Minimum 2 years work experience on a pharmacy team or in a health insurance plan.Minimum 1 year experience with managed care and/or pharmacy benefit management.Knowledge, Skills, and Abilities Required
Advanced knowledge of medical and pharmaceutical terminology.Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.Proficient with Microsoft Office Products and general computer literacy.Ability to learn and effectively navigate CareOregon and PBM software programs.Advanced listening, verbal, and written communication skills.Ability to work independently with minimal supervision and manage stress.Ability to organize, plan, and prioritize daily workflow and projects.Working Conditions
Work Environment(s): Indoor/OfficeTravel: May include occasional required or optional travel outside of the workplace.Candidates of color and veterans are strongly encouraged to apply. CareOregon is an equal opportunity employer and considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status. Visa sponsorship is not available at this time.
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