Lead Pharmacy Operations Specialist

Overview

Lead Pharmacy Operations Specialist role at WellSense Health Plan.

Reporting to the Manager of Pharmacy Support Operations, the Lead Pharmacy Operations Specialist is responsible for activities ranging from prior authorization processing to stepping in to assist in the absence of the Manager of Pharmacy Support Operations. The Lead Specialist supports all Operations Specialist staff in meeting individual goals as well as department level metrics and goals. They work closely with the management team, assist with quality control when needed, respond to pharmacy related inquiries, and assist with systems testing and troubleshooting across multiple platforms. They will meet established performance metrics and assist teammates in achieving these goals.

The Lead Specialist mentors and coaches Pharmacy Operations Specialists, fosters professionalism and teamwork, and serves as a front line resource for all team members. They act as a subject matter expert for prior authorization processing, pharmacy systems, and other Pharmacy Operations clinical, contractual and regulatory requirements. The Lead Specialist is engaged, open to answering questions, a positive role model, and contributes to the success of the team and the Pharmacy Operations department.

Key Functions/Responsibilities

• Demonstrates expert knowledge of Pharmacy Operations policies and procedures, including clinical, contractual and regulatory requirements as they relate to pharmacy.
• Serves as a subject matter expert and first line for escalated issues for Operations Specialists; exercises good judgment and involves the Manager or Senior Manager as necessary.
• Interprets and processes complex prior authorization requests for pharmacy and medical drugs.
• Performs peer audits including quality review and new employee mentoring.
• Attends interdepartmental meetings and participates in cross-functional initiatives on behalf of the department when needed.
• Demonstrates working knowledge of systems and platforms used to conduct prior authorization reviews for pharmacy and medical drugs.
• Maintains quality and performance levels for Pharmacy Operations Specialists while coordinating special team projects; includes receiving, processing, and reviewing all prior authorization requests via fax, phone, or electronic systems in compliance with regulatory and accreditation requirements.
• Properly apply clinical policy criteria to the review of prior authorization requests; review member eligibility, claim history, and Pharmacy Program information to provide information to internal and external clients via telephone or email.
• Interpret medical and pharmacy data and enter information into systems according to regulatory and NCQA accreditation requirements.
• Communicate determinations to members and providers via telephone, fax notifications, and letter notifications.
• Serve as a backup for the Pharmacy Operations Support Manager as needed.
• Test system changes and operational enhancements; act as a first-line agent on escalated calls/issues when necessary.
• Other duties as assigned by department Supervisors.

Supervision

• Occasional supervision or training of Pharmacy Operations Specialists.

Supervision Received

• Direct supervision received weekly.

Qualifications Education

• Minimum of a High School diploma or equivalent required. Associate or Bachelors degree preferred.

Experience

• Two or more years of experience in a professional or pharmacy setting required.
• Two or more years of experience in prior authorization processing required.
• Previous experience in a managed care environment preferred.
• Certified pharmacy technician preferred.
• Previous experience engaging in management activities preferred.
• Prior experience engaging in projects preferred.
• Prior customer service experience preferred.

Licensure, Certification, or Conditions of Employment

• Successful completion of 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 verbal communication skills.
• Strong data entry and attention to detail in building cases.
• Ability to multitask and be results oriented.
• Working conditions and physical effort: regular attendance is essential; ability to work in a fast-paced environment; typical office environment; minimal physical effort and risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees.

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