Pharmacy Representative

Blue Cross Blue Shield of Massachusetts•Hingham, MA

2d•$22 - $27

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. The Role The Pharmacy Operations Analyst is responsible for primary contact for our providers to obtain authorization for Medicare retail pharmacy, home infusion and medical utilization management requests. These requests are received via fax, phone and web. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email. Key Responsibilities: Receive, process, and archive provider’s retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria. Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email. Analyze and interpret high level medical data and accurately data entry information according to NCQA guidelines. Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MHK and other systems via fax or telephone. Communicate determinations to providers via incoming and outgoing telephone calls. Process pharmacy authorizations utilizing PBM real time on line claims adjudication software. Support new clinical program implementation. Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Medical Policy interpretation, and plan design interpretation. Support Medicare Part D and understanding of CMS guidelines Other responsibilities as needed. This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster. Qualification: Excellent Customer Service skills. Prior experience assisting members and/or providers with telephone inquiries. Strong organizational, problem solving, communication, and interpersonal skills. Excellent written and oral communication skills required. Must have strong data entry and attention to detail in building cases. Must be able to multitask and be results oriented. Education/Relevant Experience: Minimum of a High School diploma required. Associate or Bachelor’s degree preferred. Proficiency in MHK and CVS PBM Systems. Experience in a Windows environment preferred. Previous experience in a managed care environment preferred. Previous pharmacy experience preferred. Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above

Requirements

Excellent Customer Service skills.
Prior experience assisting members and/or providers with telephone inquiries.
Strong organizational, problem solving, communication, and interpersonal skills.
Excellent written and oral communication skills required.
Must have strong data entry and attention to detail in building cases.
Must be able to multitask and be results oriented.
Minimum of a High School diploma required.
Proficiency in MHK and CVS PBM Systems.
Experience in a Windows environment preferred.

Nice To Haves

Associate or Bachelor’s degree preferred.
Previous experience in a managed care environment preferred.
Previous pharmacy experience preferred.

Responsibilities

Receive, process, and archive provider’s retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria.
Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email.
Analyze and interpret high level medical data and accurately data entry information according to NCQA guidelines.
Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MHK and other systems via fax or telephone.
Communicate determinations to providers via incoming and outgoing telephone calls.
Process pharmacy authorizations utilizing PBM real time on line claims adjudication software.
Support new clinical program implementation.
Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Medical Policy interpretation, and plan design interpretation.
Support Medicare Part D and understanding of CMS guidelines
Other responsibilities as needed.