Pharmacy Specialist I

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Receive verbal and written requests for prior authorization from pharmacists, physicians, and/or members.

• Support and assist in coordinating Pharmacy Services benefits, including analyzing claim utilization, designing prescription plans, generating ad-hoc reports, handling correspondence, and managing special projects.

• Process prior authorization requests received via fax or the prior authorization help line by assessing medical necessity and appropriateness for specific medications based on clinical criteria.

• Manage telephonic interactions with members, physician office staff, pharmacies, and internal stakeholders concerning Pharmacy eligibility, coverage determinations, and claim-related issues.

• Collaborate with physicians and pharmacists in clinical therapeutic interchange to enhance formulary compliance, optimize generic dispensing, and ensure alignment with current plan designs.

• Accurately gather and document comprehensive clinical information for prior authorization requests to support clinical reviews and medical necessity assessments.

• Meet departmental customer service quality metrics and comply with DMAHS/DOBI regulatory turnaround times.

• Process complaints, appeals, grievances, executive inquiries, and compliance-related matters.

• Identify potential fraud, waste, and abuse and make necessary internal referrals.

• Offer suggestions to improve department efficiency, accuracy, and productivity.

• Handle ad hoc information or report requests from stakeholders.

• Engage in independent and group learning to understand pharmacy services procedures and workflows.

• Assist with daily pharmacy department operations and the Medication Therapy Management program.

• Support various clinical initiatives within the pharmacy department.

⛳️ Requirements

• High School Diploma/GED is required.

• A minimum of two (2) years of experience as a Pharmacy technician is required.

• At least two (2) years of experience in third-party prescription program claim adjudication is preferred.

• Prior experience in customer service or service quality initiatives is required.

• National Pharmacy Technician Certification (PTCB or ExCPT) is required.

• In the absence of Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization is required.

• Knowledge of popular brand and generic drug names is required.

• Familiarity with third-party prescription program claim adjudication is required.

• Working knowledge of managed care principles is required.

• Understanding of common medical terminology is required.

• Knowledge of National Drug Code (NDC) is required.

• Familiarity with State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation is required.

• Ability to utilize a personal computer and applicable software is required.

• Must possess effective verbal and written communication skills and demonstrate the ability to work collaboratively within a team.

• Ability to convey highly technical information to less technical individuals is essential.

• Must exhibit professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

• Proven time management skills; ability to juggle multiple priorities, deliver timely and accurate work products with a customer service orientation, and respond with a sense of urgency.

• Demonstrated ability to thrive in a production-focused environment.

• Proven capacity to exercise sound judgment and strong problem-solving skills.

• Proven ability to ask probing questions and gather thorough and relevant information.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous PTO.

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.