Care & Resolution Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Promptly and professionally respond to incoming member calls and inquiries.

• Oversee and enforce adherence to daily processes, protocols, and escalation pathways.

• Act as an administrative liaison among members, internal departments, pharmacies, and prescribers.

• Handle and resolve cases related to prescription claims, authorizations, and pharmacy benefit issues.

• Document results in accordance with departmental standards.

• Create effective and sustainable solutions for member challenges.

• Assist in urgent or emergency override situations as per established protocols.

• Keep abreast of pharmacy benefit workflows, including mail order, specialty pharmacy, prior authorization, accumulator management, and cost containment initiatives.

• Comprehend claims adjudication procedures, plan configurations, and client-specific benefit allowances.

• Identify root causes of member issues and suggest process enhancements.

• Remain updated on company programs, products, and processes.

• Collaborate with Clinical, Client Management, and Operations departments.

• Build trust and rapport with members through effective communication, transparency, and follow-up.

• Maintain accurate records within the member services system.

• Engage in team huddles, performance evaluations, and training sessions.

• Execute additional responsibilities as assigned.

⛳️ Requirements

• Bachelor's degree is preferred.

• A minimum of 2 years of experience in a PBM, health plan, or medication therapy management (MTM) call center; or 4 years of experience in a hospital or retail pharmacy environment.

• At least 2 years of experience in a customer service role, ideally within healthcare or pharmacy.

• Active Pharmacy Technician Certification (CPhT) is required.

• Previous experience with benefit investigations, prior authorizations, or claims processing is preferred.

• Strong customer service orientation with a dedication to concierge-level support.

• Exceptional verbal and written communication skills, including active listening and empathy.

• Proficient in Microsoft Office Suite and related systems (CRM, ticketing, or case management tools).

• Ability to think critically, solve problems, and make sound decisions under pressure.

• Outstanding time management and organizational skills; capable of managing multiple priorities in a fast-paced environment.

• Collaborative attitude with the ability to work cross-functionally to ensure resolution and client satisfaction.

🏝️ Benefits

• Paid Time Off

• 401(k) program

• Health Insurance, including Dental & Vision coverage

• Health Savings Account

• Employee Assistance Program