JOB SUMMARY:
Responsible for providing technical and customer service support for pharmacy benefits, processing prior authorizations according to CMS and State regulations, and resolving pharmacy related complaints.
KEY RESPONSIBILITIES:
- Telephone support for pharmacies and members related to pharmacy benefits for the HMO product.
- Provides resolution for various types of phone calls including, but not limited to referral, authorization, and step therapy protocols between physicians, pharmacies and members for the HMO product.
- Resolve claims adjudication issues related to pharmacy.
- Responsible for processing prior authorizations for medications.
- Work may require overtime to meet deadlines. Work may also involve dealing with members who are disgruntled or upset.
- Performs other job-related duties as assigned.
QUALIFICATIONS:
- Basic punctuation and grammar skills
- Ability to function under pressure.
- Proficient in Microsoft applications.
- Ability to work independently and apply good judgment.
- Ability to maintain and preserve information of highly confidential nature.
- Possess strong oral and written communication skills.
- Capable of project management from beginning to completion.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:
- High school diploma or equivalent.
- Two years' experience in managed care pharmacy benefits, pharmacy tech or related discipline.
- Basic understanding of Health Plan Industry.
- One year customer service experience required.
- Previous customer service experience in a Medicare Advantage plan preferred.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin