Pharmacy Resolution Specialist

Centene Corporation

2d•$16 - $27•Remote

About The Position

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 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. Remote based position anywhere in the United States, must be available to work Monday - Friday; 10:30 a.m. 7:00 p.m. EST. Position Purpose: 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. 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

Requirements

High School Diploma / GED and 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.

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