Description

JOB SUMMARY
The Pharmacy Services Specialist 2 communicates with members, providers, and clients to explain Health Plan pharmacy benefits, assist with understanding the prior authorization process, and resolve claims processing and eligibility issues while adhering to department policies and procedures.

This position advocates on behalf of the member and serves as a liaison between the Health Plan and stakeholders to identify root causes and address concerns. In addition, the Pharmacy Services Specialist 2 serves in a leadership capacity as a subject matter expert (SME) and trainer, supporting team development and ensuring operational excellence.

ESSENTIAL FUNCTIONS OF THE ROLE
Helps members by phone or in writing to effectively resolve claims processing issues for all Health Plan products, utilizing pharmacy claims systems and appropriate departmental tools.

Provide clear guidance and education to members on the fundamentals of their benefit plan, helping them maximize the value of their coverage.

Investigates and resolves complex issues, escalating cases as needed, and coordinates across multiple personnel, including outreach to pharmacies, providers, and additional partners.

Review and update member eligibility information during inquiries, adhering to HIPAA requirements and pharmacy procedures.

Establishes and maintains excellent working relationships with key operational personnel both internally and externally.

Provides coaching and training to Pharmacy Services Specialist 1 staff in collaboration with the Call Center Manager.

Collects, reviews, and reports on quality control activities for all Pharmacy Services Specialist 1 staff. Including review and auditing reports as determined by management.

Provides oversight and reporting on performance measure goals set by the pharmacy department to comply with department and regulatory standards.

KEY SUCCESS FACTORS

Certified Pharmacy Technician (CPhT) preferred.

Ability to lead a team and provide direction.

Practices good phone etiquette and uses effective communication skills (both verbal and written).

Ability to document clearly and concisely to articulate findings.

Strong customer service skills.

Excellent interpersonal, listening and communication skills.

Ability to use & navigate multiple computer applications to research and address caller needs.

Excellent analytical, problem-solving skills and attention to detail.

Knowledge of prescription terminology and pharmacy practices and procedures preferred.

Ability to work independently, as well as, in a team environment.

Ability to work in a fast-paced environment while maintaining accuracy and performance standards.

Must be proficient in typing and basic computer skills, particularly Microsoft Word and Excel.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level
QUALIFICATIONS

- EDUCATION - H.S. Diploma/GED Equivalent

- EXPERIENCE - 3 Years of Experience