Pharmacy Specialist I

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Responsible for all telephonic communication with members, staff at physician offices, pharmacies, and internal stakeholders regarding Pharmacy eligibility, coverage determinations, and/or claims issues.

• Collaborate with physicians and pharmacists to execute effective interventions through clinical therapeutic interchange, promoting formulary compliance, encouraging generic dispensing, and aligning with current plan designs.

• Accurately gather comprehensive clinical information for Prior Authorization requests from physicians and/or medical office personnel to facilitate clinical reviews and determine medical necessity.

• Ensure adherence to all departmental customer service quality metrics while consistently meeting the regulatory turnaround times mandated by DMAHS and DOBI.

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

• Identify potential instances of fraud, waste, and abuse through interactions with members and providers, and initiate necessary internal referrals.

• Offer recommendations to enhance efficiency, accuracy, and productivity within the department.

• Handle ad hoc requests for information or reports from stakeholders.

• Take responsibility for independent and group learning initiatives to guarantee understanding of pharmacy service procedures and workflows.

• Support the daily operations of the pharmacy department and the Medication Therapy Management program.

• Provide assistance to various clinical programs within the pharmacy department.

⛳️ Requirements

• High School Diploma or GED is required.

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

• Preference for at least two (2) years of experience in third-party prescription program claim adjudication.

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

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

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

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

• Knowledge of the New Jersey Board of Pharmacy regulations and State Federal controlled substances regulations is required.

🏝️ Benefits

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

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.