Pharmacy Resolution Specialist

Centene Corporation•Remote-FL, FL

23h•$16 - $27•Hybrid

About The Position

This role is for a Pharmacy Resolution Specialist on the Medical Management/Health Services team at Centene. The specialist will handle calls from members, provider/physician's offices, and pharmacies, and make outbound calls. They will enter pharmacy overrides into systems based on approved guidelines and approvals from clinical pharmacists. The role involves addressing member/prescriber/pharmacist inquiries about benefits, including prior authorization requests, and researching issues to resolve them within required turnaround times and quality standards. The specialist will also maintain expert knowledge of pharmacy benefits and formularies, including CMS regulations, and handle inbound/outbound calls for claim resolutions, prior authorizations, coverage determinations, and appeals/redeterminations. Additionally, the role requires identifying root cause issues for enterprise solutions, assisting with special projects, and performing other assigned duties while complying with all policies and standards.

Requirements

High School Diploma / GED
1 year of Job Specific call center/customer service experience.
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
Qualified candidates must be able to work either 10AM-6:30PM or 11AM - 7:30PM EST Monday-Friday.

Responsibilities

Receives and responds to calls from members, provider/physician's offices, and pharmacies.
Makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests.
Offers options including submission of a prior authorization request.
Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards.
Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines.
Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position.
Responsible for knowing and interpreting pharmacy and medical benefits.
Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates).
Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls.
Responsible for ensuring outstanding attention to detail.
Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution.
Assists with special projects as assigned.
Performs other duties as assigned.
Complies with all policies and standards.