68 applicants

Company

Horizon Blue Cross Blue Shield of New Jersey · 6 hours ago

Pharmacy Specialist I

Hopewell, NJ - Remote

Full-time

Remote

Entry Level

$43K/yr - $58K/yr

2+ years exp

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Responsibilities

Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues.

Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design.

Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination.

Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied

Process complaints, appeals, grievances, executive inquiries and compliance related issues.

Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary.

Provide recommendations to increase efficiency, accuracy and productivity in the department.

Process ad hoc request for information or reports from stakeholders.

Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows.

Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program.

Provide support to various clinical programs within the pharmacy department.

Qualification

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Pharmacy Technician CertificationThird Party Prescription ProgramManaged Care PrinciplesMedical TerminologyNational Drug Code (NDC)PC Software Proficiency

Required

High School Diploma/GED required

Requires minimum of two (2) years experience as a Pharmacy technician

Requires prior customer service/service quality initiative experience.

Requires National Pharmacy Technician Certification (PTCB or ExCPT)

In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required.

Requires knowledge of popular brand and generic drug names.

Requires knowledge of third party prescription program claim adjudication.

Requires working knowledge of managed care principles.

Requires knowledge of common medical terminology.

Requires understanding of National Drug Code (NDC).

Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation.

Requires the ability to utilize a personal computer and applicable software.

Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

Proven time management skills are necessary.

Demonstrated ability to work in a production focused environment.

Proven ability to exercise sound judgment and strong problem solving skills.

Proven ability to ask probing questions and obtain thorough and relevant information.