Pharmacy Operations Representative

3 weeks ago


Hingham, Massachusetts, United States Blue Cross Blue Shield of Massachusetts Full time
Job Summary:

We are seeking a highly skilled Pharmacy Operations Representative to join our team at Blue Cross Blue Shield of Massachusetts. As a key member of our operations team, you will be responsible for providing exceptional customer service to our providers and members, ensuring seamless authorization and processing of pharmacy requests.

Key Responsibilities:

Receive, process, and archive provider's retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria

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

Analyze and interpret high-level medical data and accurately data entry information according to NCQA guidelines

Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MHK and other systems via fax or telephone

Communicate determinations to providers via incoming and outgoing telephone calls.

Process pharmacy authorizations utilizing PBM real-time online claims adjudication software.

Support new clinical program implementation

Requirements:

High school diploma required; Associate or Bachelor's degree preferred

Proficiency in MHK and CVS PBM Systems

Experience in a Windows environment preferred

Previous experience in a managed care environment preferred

Previous pharmacy experience preferred

What We Offer:

Competitive hourly rate of $25.16

Comprehensive benefits package, including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees

Opportunities for professional growth and development

A dynamic and supportive work environment

Why Join Us:

We are committed to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. We are committed to investing in your development and providing the necessary resources to enable your success.

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