Pharmacy Benefit Specialist II

Careoregon • Salt Lake City, UT

393d • $51,800 - $63,320 • Remote

About The Position

The Pharmacy Benefit Specialist II position at CareOregon is a remote role focused on supporting members with their pharmacy benefit and prescription needs. The specialist will engage with members, providers, and pharmacies to ensure effective communication and resolution of pharmacy-related inquiries, claims processing, and prior authorizations. This role emphasizes customer service, data management, and adherence to HIPAA regulations while participating in various pharmacy projects.

Requirements

• Experience in customer service, preferably in a healthcare or pharmacy setting.
• Knowledge of pharmacy benefit management and claims processing.
• Familiarity with HIPAA regulations and confidentiality requirements.
• Strong communication skills, both verbal and written.
• Ability to work independently and manage multiple tasks effectively.

Nice To Haves

• Experience with prior authorization processes.
• Familiarity with formulary management and pharmacy policies.
• Proficiency in data entry and management systems.

Responsibilities

• Communicate in a professional and respectful manner with members, providers, and pharmacies.
• Maintain confidentiality within HIPAA regulations and function on 'need to know' principles.
• Respond to drug coverage inquiries accurately and timely.
• Educate members, providers, pharmacies, and staff about CareOregon formularies and pharmacy benefit policies.
• Document all customer service activities according to organization requirements.
• Follow policies and procedures to resolve pharmacy claims adjudication issues.
• Sort incoming faxes and distribute according to assignments.
• Maintain files according to unit protocols.
• Perform data entry into claims processing systems and databases as assigned.
• Assist with clerical tasks for pharmacy projects, including distribution of educational materials and reports.
• Verify member's plan eligibility and applicable benefits for drug coverage.
• Review medication and eligibility history for prior authorizations.
• Assist members and providers with prior authorization and formulary exception processes.
• Explain pharmacy appeal and grievance provisions to members and providers.
• Perform intake of member and provider appeals and prepare them for review.

Benefits

• Estimated hiring range of $51,800 - $63,320 per year.
• 5% bonus target.
• Full benefits package including health insurance, dental insurance, and retirement plans.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: No Education Listed