Pharmacy Benefit Specialist II

This is a fully remote position, open to applicants in Oregon, +1 more state.

📋 Description

• Deliver exceptional customer service to CareOregon members, providers, pharmacies, and staff concerning pharmacy benefits and prescription requirements.

• Process pharmacy claims while addressing or directing claims adjudication issues.

• Educate members, providers, pharmacies, and staff on formularies and pharmacy benefit policies.

• Maintain meticulous documentation of customer service interactions and uphold confidentiality in accordance with HIPAA regulations.

• Organize incoming faxes and manage filing systems.

• Conduct data entry tasks within claims processing, document management, database, and spreadsheet systems.

• Assist pharmacy projects by creating educational materials, letters, mailings, and reports.

• Validate plan eligibility and benefits for pharmaceutical coverage.

• Analyze medication and eligibility histories while entering authorizations into claims adjudication systems.

• Provide assistance with prior authorizations, formulary exceptions, and coverage determinations.

• Carry out prior authorization reviews under pharmacist supervision and communicate outcomes to relevant stakeholders.

• Manage the intake, preparation, processing, and communication of results for pharmacy appeals and grievances.

• Support pharmacists, medical directors, and coordinators in handling appeals and grievances.

• Contribute to pharmacy benefit projects focused on process enhancements, cost efficiency, policy adjustments, and outreach efforts.

⛳️ Requirements

• At least 2 years of experience working within a pharmacy team (e.g., retail, long-term care, or hospital) or 2 years in a health insurance plan.

• A minimum of 1 year of experience in managed care and/or pharmacy benefit management.

• In-depth knowledge of medical and pharmaceutical terminology.

• Strong understanding of managed care, Medicare, and Oregon Health Plan principles.

• Proficient in Microsoft Office Suite and possess general computer skills.

• Capability to learn and effectively utilize CareOregon and PBM software applications.

• Ability to adhere to and contribute to policies and procedures.

• Excellent listening, verbal, and written communication skills.

• Strong organizational, planning, and prioritization skills for daily tasks and projects.

• Capacity to work independently with minimal supervision.

• Ability to see, read, and perform repetitive finger and wrist movements for at least 6 hours per day.

• Ability to hear and communicate clearly for a minimum of 3-6 hours per day.

🏝️ Benefits

• Bonus - SIP Target, 5% Annual.

• Comprehensive medical, dental, vision, life, AD&D, and disability insurance.

• Health savings account.

• Flexible spending account(s).

• Lifestyle spending account.

• Employee assistance program.

• Wellness program.

• Discounts.

• Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.

• Retirement plan with employer contributions.

• Paid time off (PTO).

• Paid State Sick Time.

• Paid holidays.

• Volunteer time.

• Jury duty leave.

• Bereavement leave.

• 401(k) contributions.

• Opportunity to work remotely from home.