Pharmacy Operations Specialist
4-Month Contract
Remote 
Pay: $25-30/hr

Qualifications: 

• Minimum of a High School diploma or equivalent required.
• Two or more years of experience in a professional or pharmacy setting

• Associate or Bachelor’s degree preferred
• Previous experience in a managed care environment preferred
• Prior customer service experience preferred

• Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements.
• Properly apply clinical policy criteria to the review of prior authorization requests
• Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email
•  Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements
• Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications
• Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
• Provide pharmacy-related customer service to both internal and external parties.
• Process pharmacy authorizations utilizing PBM real time online claims adjudication software.
• Support new clinical program implementation
• Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation.
• Other responsibilities as needed