Pharmacy Operations Specialist

Manager feedback: Retail pharmacy with working drug knowledge is ok; payer background preferred.

Job Summary:

Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the Client pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties
In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed.

Key Functions/Responsibilities:

Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements.
Properly apply clinical policy criteria to the review of prior authorization requests
Review and interpret member s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email
Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements
Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications
Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
Provide pharmacy-related customer service to both internal and external parties.
Process pharmacy authorizations utilizing PBM real time online claims adjudication software.
Support new clinical program implementation
Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation.
Other responsibilities as needed



Supervision Exercised:

None

Supervision Received:

General supervision received daily

Qualifications:



Education:

Minimum of a High School diploma or equivalent required
Associate or Bachelor s degree preferred

Experience:
Two or more years of experience in a professional or pharmacy setting
Previous experience in a managed care environment preferred
Prior customer service experience preferred

Certification or Conditions of Employment:

Pre-employment background check

Competencies, Skills, and Attributes:

Excellent Customer Service skills
Prior experience assisting members and/or providers with telephone inquiries
Strong organizational, problem solving, communication, and interpersonal skills
Excellent written and oral communication skills required.
Must have strong data entry and attention to detail in building cases
Must be able to multitask and be results oriented