Pharmacy Specialist I

Horizon Healthcare Services•Hopewell, NJ

About The Position

The Pharmacy Specialist I receives verbal and written prior authorization requests from pharmacists, physicians, and members. The role supports coordination of Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence, and special projects. The specialist processes requests received by fax or through the prior authorization help line, evaluating medical necessity and appropriateness against clinical criteria while meeting organizational goals and regulatory requirements. The position also handles pharmacy eligibility, coverage determinations, and claim issues; supports customer service quality and regulatory turnaround-time requirements; and assists with pharmacy department operations and clinical programs, including the Medication Therapy Management program.

Requirements

High school diploma or GED.
At least two years of experience as a pharmacy technician.
Prior customer service or service quality initiative experience.
National Pharmacy Technician Certification (PTCB or ExCPT), or at least five years of experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM organization in lieu of certification.
Knowledge of popular brand and generic drug names, third-party prescription program claim adjudication, managed care principles, common medical terminology, and the National Drug Code (NDC).
Knowledge of New Jersey Board of Pharmacy regulations and state and federal controlled substances regulations.
Ability to use a personal computer and applicable software.
Effective verbal and written communication skills and ability to work well within a team.
Ability to communicate highly technical information to less technical individuals.
Professional and ethical business practices, adherence to company standards, and commitment to personal and professional development.
Proven time management skills and ability to manage multiple priorities, deliver timely and accurate work with a customer service focus, and respond urgently when needed.
Ability to work in a production-focused environment and exercise sound judgment and strong problem-solving skills.
Ability to ask probing questions and obtain thorough and relevant information.

Nice To Haves

At least two years of experience in third-party prescription program claim adjudication.

Responsibilities

Handle telephonic interactions with members, physician office staff, pharmacies, and internal stakeholders regarding Pharmacy eligibility, coverage determinations, and claim issues.
Engage physicians and pharmacists in clinical therapeutic interchange interventions to support formulary compliance, generic dispensing, and consistency with current plan design.
Capture accurate and comprehensive clinical information for prior authorization requests to support clinical review and medical necessity determinations.
Meet departmental customer service quality metrics and applicable DMAHS and DOBI regulatory turnaround times.
Process complaints, appeals, grievances, executive inquiries, and compliance-related issues.
Identify potential fraud, waste, and abuse through interactions with members and providers and make necessary internal referrals.
Recommend ways to improve departmental efficiency, accuracy, and productivity.
Process ad-hoc requests for information or reports from stakeholders.
Participate in independent and group learning to understand Pharmacy Services procedures and workflows.
Assist with day-to-day pharmacy department business functions and the Medication Therapy Management program.
Support clinical programs within the pharmacy department.