Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed. Key Functions/Responsibilities: • Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements. • Properly apply clinical policy criteria to the review of prior authorization requests • 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 • Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements • Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications • Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits • Provide pharmacy-related customer service to both internal and external parties. • Process pharmacy authorizations utilizing PBM real time online claims adjudication software. • Support new clinical program implementation • Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation. • Other responsibilities as needed Qualifications: • Minimum of a High School diploma or equivalent required. Associate or Bachelor’s degree preferred Experience: • Two or more years of experience in a professional or pharmacy setting • Previous experience in a managed care environment preferred • Prior customer service experience preferred • 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 oral communication skills required. • Must have strong data entry and attention to detail in building cases • Must be able to multitask and be results oriented
