Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.
Job Title: Pharmacy Benefit Specialist II
Exemption Status: Non-Exempt
Department: Pharmacy
Manager Title: Pharmacy Benefit Operations Supervisor
Direct Reports: n/a
Requisition #: 24529
Pay and Benefits: Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits. View Benefits
Posting 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.
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 in an accurate and timely manner 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 as it pertains to the CareOregon 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 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, 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 provider staff 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 & reconsiderations, gather data & documentation, and prepare appeals for review by CareOregon 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.
Project Coordination
- 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.
Organizational Responsibilities
- Perform work in alignment with the organization's mission, vision, and values.
- Support the organization's commitment to equity, diversity, and inclusion by fostering a culture of open-mindedness, cultural awareness, compassion, and respect for all individuals.
- Strive to meet annual business goals in support of the organization's strategic goals.
- Adhere to the organization's policies, procedures, and other relevant compliance needs.
- Perform other duties as needed.
Experience and/or Education
Required
- 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.
Knowledge, Skills and Abilities Required
Knowledge
- Advanced knowledge of medical and pharmaceutical terminology.
- Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Skills and Abilities
- Proficient with Microsoft Office Products and general computer literacy.
- Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities.
- Ability to follow and provide input into policies and procedures in performing job responsibilities.
- Advanced listening, verbal, and written communication skills.
- Ability to exercise professionalism.
- Proficient 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 seek or determine appropriate resolution.
- Ability to accept managerial direction and feedback.
- Ability to tolerate and manage stress.
- Results and service-oriented.
- Ability to be flexible and adaptable.
- Ability to organize, plan, and prioritize daily workflow and projects within time constraints.
- Ability to work in an environment with diverse individuals and groups.
- Ability to work independently with minimal supervision.
- Ability to learn, focus, understand, and evaluate information and determine appropriate actions.
- Ability to accept direction and feedback, as well as tolerate and manage stress.
- Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day.
- Ability to hear and speak clearly for at least 3-6 hours/day.
Working Conditions
Work Environment(s): Indoor/Office, Community, Facilities/Security, Outdoor Exposure
Member/Patient Facing: No, Telephonic, In Person
Hazards: May include, but not limited to, physical and ergonomic hazards.
Travel: May include occasional required or optional travel outside of the workplace; the employee's personal vehicle, local transit, or other means of transportation may be used.
Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.
Veterans are strongly encouraged to apply.
We are an equal opportunity employer. CareOregon 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.
