Customer Service - Pharmacy Technical Support Specialist 176-1030
About The Position
JOB SUMMARY: Focus on prospective, concurrent and retrospective review of medical services provided to members enrolled in CommunityCare. Take into consideration benefits members are entitled to, access to services, site of care, the quality of services rendered and the cost of care. Provides medically appropriate services that are a covered benefit to members with attention focused on quality and efficiency. Provides Quality of care services in a cost-effective manner to preserve member benefits and minimize unnecessary healthcare costs. Processes are conducted, and decisions are made in compliance with State and Federal utilization management regulations. This position will report to the director of pharmacy.
Requirements
- High school diploma or equivalent.
- Two years' experience in managed care pharmacy benefits, pharmacy tech or related discipline.
- Basic understanding of Health Plan Industry.
- One year customer service experience required.
- Ability to read, comprehend, and explain health insurance benefits in a clear, concise, and professional manner.
- Dedicated to working in a collaborative, multi-team environment to provide the best care for our members.
- Ability to work independently and apply good judgment.
- Proficient in Microsoft Office applications.
- Highly organized and attentive to detail.
- Strong time management skills.
- Successful completion of Health Care Sanctions background check.
Nice To Haves
- Experience in managed care, PBM, or health plan setting preferred
- Knowledge of infusion therapies is preferred.
- Previous customer service experience in a Medicare Advantage plan preferred.
Responsibilities
- Process incoming authorization requests regarding services for members from providers
- Verifies eligibility, claim status, coinsurance and all other information related to a member and their benefits or a provider and their contract.
- Collaborate with healthcare providers for clinical information needed for determination requests.
- Accurately document case interactions with healthcare providers and members.
- Resolve claims adjudication issues related to medical benefits.
- Demonstrate ability and learning agility to adapt to organizational changes including business processes, systems and technology.
- Taking part in training and other learning opportunities to expand knowledge of company and position.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Industry
Hospitals
Education Level
High school or GED
Number of Employees
251-500 employees
