[Hiring] Pharmacy Specialist I @Horizon Blue Cross Blue Shield of New Jersey

Role Description

This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including:

• Claim utilization analysis
• Prescription plan design
• Ad-hoc reporting
• Correspondence and special projects

This position must ensure performance is in compliance with organizational or departmental goals and regulatory agencies. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs based on clinical criteria.

What You'll Do

• Responsible for all telephonic interaction with members, physician office staff, pharmacies, and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues.
• Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design.
• Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination.
• Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied.
• Process complaints, appeals, grievances, executive inquiries, and compliance-related issues.
• Responsible for identifying instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary.
• Provide recommendations to increase efficiency, accuracy, and productivity in the department.
• Process ad hoc requests for information or reports from stakeholders.
• Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows.
• Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program.
• Provide support to various clinical programs within the pharmacy department.

Qualifications

• High School Diploma/GED required
• Minimum of two (2) years experience as a Pharmacy technician
• Preferred minimum of two (2) years experience in third party prescription program claim adjudication
• Prior customer service/service quality initiative experience
• Requires National Pharmacy Technician Certification (PTCB or ExCPT)
• In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM organization required

Requirements

• Knowledge of popular brand and generic drug names
• Knowledge of third party prescription program claim adjudication
• Working knowledge of managed care principles
• Knowledge of common medical terminology
• Understanding of National Drug Code (NDC)
• Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation

Skills and Abilities

• Ability to utilize a personal computer and applicable software
• Effective verbal and written communication skills
• Ability to work well within a team
• Ability to deliver highly technical information to less technical individuals
• Demonstrated professional and ethical business practices
• Proven time management skills
• Ability to manage multiple priorities and deliver timely and accurate work products
• Ability to work in a production-focused environment
• Proven ability to exercise sound judgment and strong problem-solving skills
• Proven ability to ask probing questions and obtain 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

Salary Range

$44,600 - $59,745

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.