Pharmacy Specialist I

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

📋 Description

• Receive both verbal and written prior authorization requests from pharmacists, physicians, and members.

• Assist in the coordination of Pharmacy Services benefits, which includes analyzing claim utilization, designing prescription plans, generating ad-hoc reports, managing correspondence, and overseeing special projects.

• Evaluate medical necessity and appropriateness when processing prior authorization requests received through fax or the prior authorization help line, using established clinical criteria.

• Manage telephonic communications with members, physician office staff, pharmacies, and internal team members regarding eligibility, coverage determinations, and claim-related issues.

• Collaborate with physicians and pharmacists on clinical therapeutic interchange interventions to enhance formulary compliance and promote the use of generic medications.

• Accurately capture comprehensive clinical information for prior authorization requests.

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

• Detect potential fraud, waste, and abuse, making necessary internal referrals.

• Offer suggestions to enhance departmental efficiency, accuracy, and productivity.

• Handle ad-hoc information requests or report requests from stakeholders.

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

• Support daily functions of the pharmacy department and assist with the Medication Therapy Management program.

• Contribute to clinical programs within the pharmacy department.

• Adhere to departmental customer service quality standards and regulatory turnaround times.

⛳️ Requirements

• High School Diploma or GED is required.

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

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

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

• Alternatively, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM organization is acceptable in lieu of certification.

• Familiarity with common brand and generic drug names is essential.

• Understanding of third-party prescription program claim adjudication is required.

• Working knowledge of managed care principles is necessary.

• Knowledge of common medical terminology is important.

• Understanding of the National Drug Code (NDC) is required.

• Awareness of New Jersey Board of Pharmacy regulations and state/federal controlled substances regulations is needed.

• Proficiency in using a personal computer and relevant software is essential.

• Strong verbal and written communication skills are required.

• Ability to convey complex technical information to less technical individuals is necessary.

• Commitment to professional and ethical business practices and adherence to company standards.

• Effective time management skills and the ability to manage multiple priorities are required.

• Ability to produce timely and accurate work products with a customer service orientation is necessary.

• Comfortable working in a production-focused environment.

• Possess sound judgment and strong problem-solving skills.

• Ability to ask insightful questions and gather thorough, relevant information is essential.

🏝️ Benefits

• Comprehensive health benefits including Medical, Dental, and Vision.

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.