Pharmacy Benefit Specialist II
3 weeks ago
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.
Key Responsibilities- Customer Service and Claims Processing
- Communicate in a professional and respectful manner with members, providers, and pharmacies.
- Maintain confidentiality within HIPAA regulations and function on 'need to know' principles.
- Respond to drug coverage inquiries in an accurate and timely manner.
- Data Entry and Clerical Support
- 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.
- Prior Authorizations (PA) and Formulary Exceptions
- 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.
- Appeals and Grievances
- Explain pharmacy appeal and grievances provisions and process to members, providers, and CareOregon staff.
- Perform intake of member and provider appeals & reconsiderations, gather data & documentation, and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
This is an advanced level support position, requiring Pharmacy Technician Certification. The ideal candidate will have excellent communication and problem-solving skills, as well as the ability to work in a fast-paced environment.
CareOregon is a non-profit health plan that serves Oregon's most vulnerable populations. We are committed to providing high-quality care and services to our members, and we are seeking a dedicated and compassionate individual to join our team.
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