Pharmacy Benefits Specialist I

Menasha • Menasha, WI

9d • Hybrid

About The Position

The Pharmacy Benefits Specialist I provides basic operational, planning, implementation, reporting, and administrative support for the Pharmaceutical Benefits area of Network Health Plan. The role builds report queries and maintains operational and financial reports; researches and resolves claim-processing and benefit issues; serves as a technical resource for internal users regarding pharmacy benefits; and maintains pharmacy formularies in written and web formats.

Candidates must reside in Wisconsin. The position follows a hybrid workplace model, combining work from a home office (with reliable internet) and the company office. The schedule is 1.0 FTE, 40 hours per week, Monday through Friday, 8:00 a.m. to 5:00 p.m.

Requirements

• High school diploma or equivalency.
• One year of experience in a Pharmacy Technician position or one year of experience working with pharmacy benefits.

Nice To Haves

• Certified Pharmacy Technician; one year of experience working with pharmacy benefits may substitute for certification.

Responsibilities

• Manage large mailings, including letter preparation, mail merge, and distribution.
• Create and maintain Prescription Benefit Summary of Member Responsibility tables.
• Provide reports for internal and external stakeholders, including prior authorization, physician utilization, controlled substance reporting, the Annual Quality Improvement Program Evaluation, call log and drug reports related to the Key Performance Indicator Board, and standard reports from the Pharmacy Benefits Manager (PBM) in coordination with Sales.
• Complete file reviews for denials.
• Maintain J-Code Tier Levels billing tables for claims.
• Answer formulary status questions from Commercial and Medicare Sales and Customer Service.
• Assist Care Management and Disease Management with benefit questions, prior authorization requirements, and grievances.
• Pull data for reporting pharmacy trends.
• Manage the PBM Satisfaction Survey process.
• Research and resolve benefit issues.
• Perform benefit testing.
• Perform other duties and responsibilities as assigned.

Benefits

• Opportunity to get paid to volunteer in the local community.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED