Pharmacy Benefits Specialist - St. Luke's Health Plan

St. Luke's Health System•Boise, ID

17d

About The Position

Overview At St. Luke’s, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke’s is truly a great place to work. Overview: The Pharmacy Benefits Specialist assists our members in identifying and navigating complex pharmacy benefits management (PBM) and third-party issues such as prior authorization, step therapy, reviewing denied claims, and processing overrides. Works with an interdisciplinary team of pharmacy staff, patient financial advocates, the pharmacy authorization team, clinic staff, and providers. Issues insurance overrides and processes prior authorizations. What to expect: Establish and maintain collaborative working relationships with pharmacies, members, and providers. Will serve as first-line contact for escalated pharmacy, member, and provider concerns. Will assist in the training and onboarding of all new pharmacy benefits team members. Review the supporting clinical documentation provided by a patient's prescriber and validate that information against the drug and therapeutic indication for that situation. Apply in-depth knowledge of high-cost specialty medications, the applicable pharmaceutical regulations, and requirements to align member and Health Plan cost containment strategies. Navigate federal laws that may impact patients from participating in manufacturer copay card programs. Accurately calculate costs and savings while processing specialty medications. Provide customer service and explain complex insurance topics to patients and providers. Apply working knowledge of insurance plan design and terminology (deductible, max out of pocket, co-insurance, etc.) Interpret medical terminology and accurately process prior authorization requests for medications under the pharmacy benefits. Facilitate resolutions to issues involving claims adjudication, member concerns, and provider communications. Addresses complex questions from third-party payers and medical staff regarding medication issues and reimbursement. Serve as subject matter expert (SME) on resolving claim rejections, copay assistance programs, and escalated prior authorization appeals. Will assist in preparing for and leading team member meetings. Serves as a role model and mentor to other Pharmacy Benefits Specialists. Performs other duties and responsibilities as assigned.

Requirements

High School diploma or equivalent
1 years of experience
Valid Idaho Pharmacy Technician License

Responsibilities

Assists our members in identifying and navigating complex pharmacy benefits management (PBM) and third-party issues such as prior authorization, step therapy, reviewing denied claims, and processing overrides.
Works with an interdisciplinary team of pharmacy staff, patient financial advocates, the pharmacy authorization team, clinic staff, and providers.
Issues insurance overrides and processes prior authorizations.
Establish and maintain collaborative working relationships with pharmacies, members, and providers.
Will serve as first-line contact for escalated pharmacy, member, and provider concerns.
Will assist in the training and onboarding of all new pharmacy benefits team members.
Review the supporting clinical documentation provided by a patient's prescriber and validate that information against the drug and therapeutic indication for that situation.
Apply in-depth knowledge of high-cost specialty medications, the applicable pharmaceutical regulations, and requirements to align member and Health Plan cost containment strategies.
Navigate federal laws that may impact patients from participating in manufacturer copay card programs.
Accurately calculate costs and savings while processing specialty medications.
Provide customer service and explain complex insurance topics to patients and providers.
Apply working knowledge of insurance plan design and terminology (deductible, max out of pocket, co-insurance, etc.)
Interpret medical terminology and accurately process prior authorization requests for medications under the pharmacy benefits.
Facilitate resolutions to issues involving claims adjudication, member concerns, and provider communications.
Addresses complex questions from third-party payers and medical staff regarding medication issues and reimbursement.
Serve as subject matter expert (SME) on resolving claim rejections, copay assistance programs, and escalated prior authorization appeals.
Will assist in preparing for and leading team member meetings.
Serves as a role model and mentor to other Pharmacy Benefits Specialists.
Performs other duties and responsibilities as assigned.