Pharmacy Benefit Specialist II

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

📋 Description

• Assist CareOregon members, healthcare providers, and pharmacies with their pharmacy benefit and prescription requirements under the major medical benefit.

• Deliver customer service and manage pharmacy claims processing.

• Address drug coverage questions and inform members, providers, pharmacies, and staff about formularies and pharmacy benefit regulations.

• Record customer service interactions and uphold confidentiality in accordance with HIPAA standards.

• Conduct data entry for claims processing, document management, databases, and spreadsheet systems.

• Organize incoming faxes and maintain filing systems.

• Support pharmacy initiatives, educational resources, correspondence, mailings, and reporting tasks.

• Confirm plan eligibility and verify drug coverage benefits.

• Examine medication and eligibility records, and input authorizations into claims adjudication systems.

• Facilitate prior authorization, formulary exceptions, and coverage determination processes.

• Carry out prior authorization evaluations with pharmacist oversight and communicate the outcomes.

• Handle pharmacy appeals and grievances by collecting documentation, preparing cases for review, and informing members and providers of the results.

• Contribute to process enhancements, cost-saving initiatives, benefit implementations/changes, and outreach projects under the guidance of a pharmacist or operations supervisor.

• Work is scheduled from Monday to Friday.

⛳️ Requirements

• At least 2 years of experience on a pharmacy team or a minimum of 2 years in a health insurance plan.

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

• Advanced understanding of medical and pharmaceutical terminology.

• Significant knowledge of managed care, Medicare, and Oregon Health Plan principles.

• Proficient in Microsoft Office applications and general computer skills.

• Capability to learn and operate CareOregon and PBM software programs.

• Strong listening, verbal, and written communication skills.

• Ability to perform repetitive finger and wrist movements for a minimum of 6 hours each day.

• Capability to hear and speak clearly for at least 3–6 hours each day.

• Pharmacy Technician Certification (CPhT) is preferred.

• Experience as a Pharmacy Technician is preferred.

• Experience with pharmacy-related outbound calls is preferred.

🏝️ Benefits

• Bonus opportunities; 5% annual SIP target.

• 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 for non-benefits-eligible employees.