Senior Pharmacy Resolution Specialist

Centene Corporation

About The Position

The Senior Pharmacy Resolution Specialist acts as a subject matter expert, handling complex pharmacy issues and responding to escalated calls from members, providers, and pharmacies. This role involves making outbound calls and entering pharmacy overrides based on approved guidelines and clinical pharmacist approvals. The specialist will take inquiry calls for benefit questions, including prior authorization requests, and offer options such as submitting prior authorization requests. They are expected to thoroughly research and resolve issues within specified turnaround times and quality standards, including claims resolution through inbound and outbound calls. The position also involves assisting and guiding less experienced team members, participating in their training, and acting as a liaison between internal departments for data gathering and problem-solving. Additionally, the specialist will investigate unusual problems, present proposed solutions, and assist with audit preparation and special projects. Candidates must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.

Requirements

High School Diploma / GED
2 years of experience
Call center / customer service experience
Experience in healthcare environment (pharmacy operations, managed care, pharmacy hospitals and or pharmacy retail settings)
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.

Nice To Haves

Pharmacy technician certification preferred

Responsibilities

Act as a subject matter expert and handle more complex pharmacy issues.
Respond to escalated calls from members, provider/physician's offices and pharmacies.
Make outbound calls and enter pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
Take member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests.
Offer options including submission of a prior authorization request.
Thoroughly research issues and take appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards.
Answer and conduct inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates).
Thoroughly research issues and take appropriate action to resolve them within turnaround time requirements and quality standards.
Assist team members often guiding them to the appropriate resolution of more complex and difficult inquiries.
Participate in the training of less experienced staff, including opportunity for job shadowing.
Act as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility.
Present proposed solutions in a clear and concise manner.
Assist with audit preparation as needed.
Assist with miscellaneous special project work as assigned.
Perform other duties as assigned.
Comply with all policies and standards.