Our Client, a Health Insurance company, is looking for a Pharmacy Specialist I for their Newark, NJ/Hybrid location.
Responsibilities:
Process prior authorizations received via prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs and based on medical criteria.
Directly interact with members physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues.
Conduct intervention with physician & pharmacy office staff to facilitate formulary compliance and generic dispensing.
Process appeals complaints executive inquiries and compliance related issues.
Provide recommendations to increase efficiency, accuracy and productivity in the department.
Process ad hoc request for information or reports from stakeholders.
Participate in client member and employee training to ensure practical understanding of pharmacy services programs and operations.
Assist in the day to day business functions of the pharmacy department as well as the Medication Therapy Management program.
Provide support to various clinical programs within the pharmacy department.
Requirements:
Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration.
Requires minimum of two (2) years experience in third party prescription program claim adjudication.
Requires minimum of two (2) years experience as a Pharmacy Utilization Management Specialist.