Healthcare Transformation Coordinator

1 week ago


Hingham, Massachusetts, United States Blue Cross Blue Shield of Massachusetts Full time

Join Our Team at Blue Cross Blue Shield of Massachusetts

We are a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. With over 75 years of experience, we are consistently ranked among the nation's best health plans.

We are seeking a skilled Pharmacy Operations Representative to join our team. In this role, you will be responsible for primary contact with providers to obtain authorization for retail pharmacy, home infusion, and medical utilization management requests. You will also support inquiries from other business areas via phone and email.

This is an excellent opportunity for individuals who are passionate about delivering exceptional customer service and have strong organizational, problem-solving, communication, and interpersonal skills.

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
  • Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Medical Policy interpretation, and plan design interpretation
  • Support Medicare Part D and understanding of CMS guidelines
  • Other responsibilities as needed

Salary: The estimated salary for this position is around $43,000 - $52,000 per year, based on a 40-hour workweek. This job is also eligible for variable pay. We offer a comprehensive package of benefits, including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.



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