Pharmacy Specialist I

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

📋 Description

• Oversee all telephonic communications with members, physician office staff, pharmacies, and internal stakeholders regarding Pharmacy eligibility, coverage determinations, and claim-related issues.

• Collaborate with physicians and pharmacists to implement effective interventions through clinical therapeutic interchange, promoting formulary adherence, optimizing generic dispensing, and ensuring alignment with the current plan design.

• Accurately gather and document comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to facilitate clinical review and assess medical necessity.

• Ensure all departmental customer service quality metrics are met while consistently adhering to the regulatory turnaround times required by DMAHS and DOBI.

• Address and process 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 suggestions to enhance efficiency, accuracy, and productivity within the department.

• Handle ad hoc information requests or reports from stakeholders.

• Responsible for both independent and group training to ensure comprehension of pharmacy services procedures and workflows.

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

• Assist various clinical programs within the pharmacy department.

⛳️ Requirements

• A High School Diploma or GED is required.

• At least two (2) years of experience as a Pharmacy technician is necessary.

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

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

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

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

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

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

• A working understanding of managed care principles is essential.

• Knowledge of common medical terminology is required.

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

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

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement