Apply on Employer Site

Horizon Blue Cross Blue Shield of New Jersey · 1 day ago

Pharmacy Specialist l

United States

Full-time

Remote

Entry, Mid Level

$45K/yr - $60K/yr

2+ years exp

Horizon Blue Cross Blue Shield of New Jersey empowers its members to achieve their best health and is seeking a Pharmacy Specialist I to support Pharmacy Services benefits. This role involves processing prior authorization requests and ensuring compliance with organizational goals and regulatory standards.

Health Care

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

National Pharmacy Technician CertificationPharmacy technician experienceThird party claim adjudicationDrug namesManaged care principlesMedical terminologyNational Drug Code (NDC)Pharmacy regulations knowledgeEffective communicationTime managementProblem solvingTeamwork

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

Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required

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