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CareOregon · 20 hours ago

Pharmacy Benefit Specialist-2

United States

Full-time

Remote

Entry Level

$20.51/hr - $25.06/hr

1+ years exp

CareOregon is a health organization focused on providing pharmacy benefits and prescription support. The Pharmacy Benefit Specialist-2 is responsible for customer service, claims processing, and assisting with prior authorizations and formulary exceptions for members and providers.

Health Care

Responsibilities

Communicate in a professional and respectful manner

Maintain confidentiality within HIPAA regulations and function on “need to know” principles

Respond to drug coverage inquires 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

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

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 providers staff of prior authorization and formulary exception decisions

Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff

Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances

Minimal project participation

Qualification

Pharmacy benefit knowledgeClaims processingCustomer serviceMicrosoft Office proficiencyMedical terminology familiarityProfessionalismEffective communicationCritical thinkingAdaptabilityOrganizational skills

Required

Minimum 1 year work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 1 year experience in a health insurance plan

General understanding of managed care, Medicare, and Oregon Health Plan concepts

Proficient with Microsoft Office Products and general computer literacy

Familiarity with medical and pharmaceutical terminology

Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities

Ability to follow policies and procedures in performing job responsibilities

Effective listening, verbal, and written communication skills

Ability to exercise professionalism

Growing 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 use critical thinking skills and company resources to determine a solution

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 within time constraints

Ability to work in an environment with diverse individuals and groups

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

Benefits

Medical

Dental

Vision

Life

AD&D

Disability insurance

Health savings account

Flexible spending account(s)

Lifestyle spending account

Employee assistance program

Wellness program

Discounts

Multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)

Strong retirement plan with employer contributions

PTO

Paid State Sick Time

Paid holidays

Volunteer time

Jury duty

Bereavement leave