[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 through interactions with members and providers, leading to necessary internal referrals.
• 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

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

Skills and Abilities

• Requires the 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, adherence to company standards, and commitment to personal and professional development
• Proven time management skills; ability to manage multiple priorities and deliver timely and accurate work products with a customer service focus
• Demonstrated 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

Disclaimer

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.