Requisition ID 24529 - Posted - CareOregon - Full-Time - Permanent - Portland - Multi Location (18)
Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.
Job Title
Pharmacy Benefit Operations Supervisor
Exemption Status
Non-Exempt
Department
Pharmacy
Direct Reports
n/a
Requisition #
24529
Pay and Benefits
Estimated hiring range $51,800 - $63,320 /year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/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.
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, representatives, providers, and CareOregon staff.
- Educate members, providers, pharmacies, and CareOregon staff about formularies and pharmacy benefit policies.
- Document all activities according to organization requirements.
- Follow policies and procedures to address questions regarding claims processing related to pharmacy benefits.
- Determine resolutions to pharmacy claims adjudication issues or triage to other 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 claims processing systems and databases as assigned.
- Provide clerical assistance for pharmacy projects, including distribution of educational materials.
Prior Authorizations (PA) and Formulary Exceptions
- Verify member’s plan eligibility and applicable benefit for drug coverage.
- Review member’s medication and eligibility history.
- Assist members and providers with PA and formulary exception processes.
- Facilitate resolutions for prior authorization requests.
- Perform prior authorization reviews with pharmacist oversight.
Appeals and Grievances
- Explain appeal and grievance provisions and processes to members and providers.
- Perform intake of member and provider appeals, gather data, and prepare for review.
- Complete pharmacy appeals and notify members and providers of outcomes.
- Assist with processing pharmacy benefit appeals and grievances.
Project Coordination
- Assist with pharmacy benefit projects including process improvements and 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.
- Strive to meet annual business goals.
- Adhere to the organization’s policies and compliance needs.
- Perform other duties as needed.
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 and Oregon Health Plan concepts.
- Proficient with Microsoft Office Products and general computer literacy.
- Ability to learn and effectively navigate relevant software programs.
- Advanced communication skills, both verbal and written.
- Ability to work independently with minimal supervision.
Working Conditions
Hazards: May include physical and ergonomic hazards.
Travel: May include occasional required or optional travel outside of the workplace.
Candidates of color and veterans are strongly encouraged to apply. CareOregon is committed to building a diverse and inclusive work environment.
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.
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