Pharmacy Specialist I

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

3d•$44,600 - $59,745

About The Position

This position receives verbal and written prior authorization requests from pharmacists, physicians, and members. It supports and assists with coordinating Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad hoc reporting, correspondence, and special projects. The role processes prior authorization requests received by fax or through the prior authorization help line by evaluating medical necessity and appropriateness for specific drugs against clinical criteria. The position is accountable for meeting organizational and departmental goals and complying with regulatory requirements. The Pharmacy Specialist I also supports Pharmacy Department day-to-day business functions, the Medication Therapy Management program, and various clinical programs. Horizon employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

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, in lieu of certification, at least five years of experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a Pharmacy Benefit Management (PBM) organization.
Knowledge of popular brand and generic drug names.
Knowledge of third-party prescription program claim adjudication.
Working knowledge of managed care principles.
Knowledge of common medical terminology.
Understanding of 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, including the ability to explain highly technical information to less technical individuals.
Professional and ethical business practices, adherence to company standards, and commitment to personal and professional development.
Time management skills and ability to manage multiple priorities, deliver timely and accurate work with a customer service focus, and respond with urgency as needed.
Ability to work in a production-focused environment.
Sound judgment and strong problem-solving skills.
Ability to ask probing questions and obtain thorough, 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 the current plan design.
Capture accurate and comprehensive clinical information for prior authorization requests so they can be clinically reviewed and medical necessity determined.
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 information or report requests 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 various clinical programs within the Pharmacy Department.
Support and assist in coordinating Pharmacy Services benefits, including claim utilization analysis, prescription plan design, reporting, correspondence, and special projects.
Process prior authorization requests received by fax or the prior authorization help line by evaluating medical necessity and appropriateness against clinical criteria.