Pharmacy Resolution Specialist

Centene Corporation

23h

About The Position

The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists. The specialist takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests, offers options including submission of a prior authorization request, and thoroughly researches issues to resolve them using appropriate reference material within turnaround time requirements and quality standards. They log, track, resolve, and respond to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines, with special care to enhance Centene relationships and meet/exceed performance standards. The role involves maintaining expert knowledge on all pharmacy benefits and formularies, including CMS regulations, and interpreting pharmacy and medical benefits. They answer and conduct inbound and outbound calls with members and provider offices to provide resolution to claims (e.g., additional information requests and medication determination updates), and are actively involved in initiating and providing status for prior authorization/coverage determination, appeal/redetermination phone calls. The specialist is responsible for ensuring outstanding attention to detail, identifying root cause issues for enterprise solutions, communicating findings for first call resolution, assisting with special projects, and performing other duties as assigned, while complying with all policies and standards.

Requirements

High School Diploma / GED
1 year of Job Specific call center/customer service
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Must be available to work 9:30AM-6:00PM EST.

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 in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards.
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