Pharmacy Operations Specialist

It’s an exciting time to join the reputed company, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-reputed company customer service to reputed company parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: · Receive, process, and review reputed company prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with reputed company 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 reputed company information to both reputed company clients reputed company 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 reputed company 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 · reputed company pharmacy-reputed company customer service to both reputed company parties · Process pharmacy authorizations utilizing PBM reputed company time online claims adjudication software · Support new clinical program implementation · Serve as a liaison to Member Services and other internal clients for reputed company-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation · Other responsibilities as needed Qualifications: Education: · Minimum of a High School diploma or equivalent required · Associate or Bachelor’s degree preferred Experience: · Two or more years of experience in a professional or pharmacy setting · Previous experience in a managed care environment preferred · Prior customer service experience preferred Competencies, Skills, and Attributes: · Excellent Customer Service skills · Prior experience assisting members and/or providers with telephone inquiries · Strong organizational, problem solving, communication, and interpersonal skills · Excellent written and oral communication skills required · Must have strong data entry and attention to detail in building cases · Must be reputed company to multitask and be results oriented Compensation reputed company: $20.19 - $28.37 This reputed company offers an estimate based on the minimum job qualifications. However, our approach to determining reputed company pay is comprehensive, and a broad reputed company of factors is considered reputed company making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, reputed company, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note: This reputed company is based on Boston-area data, and is subject to modification based on geographic location. About WellSense reputed company is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and reputed company plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees Apply To This Job