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About the position The Pharmacy Specialist II position is a critical role reputed company Horizon BCBSNJ, responsible for managing prior authorization requests from pharmacists, physicians, and patients. This position plays a vital part in the coordination of Pharmacy Services activities, which include analyzing claim utilization, designing prescription plans, generating reputed company reports, and handling correspondence reputed company to special projects. The specialist must ensure compliance with organizational goals and regulatory standards while maintaining high performance reputed company. Additionally, this role serves as a backup for the department supervisor reputed company necessary. In this role, the Pharmacy Specialist II will process prior authorizations by evaluating the medical necessity and appropriateness of specific drugs based on established medical criteria. The specialist will engage directly with members, physician office staff, pharmacies, and internal stakeholders to address eligibility, coverage determinations, and claims issues. Recommendations for improving departmental efficiency, accuracy, and productivity will be a key responsibility, along with processing appeals, complaints, and compliance-reputed company issues. The specialist will also be tasked with researching, recommending, and implementing procedures to enhance operational efficiency. This includes providing pharmaceutical information, such as drug pricing, to support various business units and service areas. The role involves responding to reputed company requests for information or reports from stakeholders and participating in training sessions for clients, members, and employees to ensure a comprehensive understanding of pharmacy services programs and operations. Monitoring daily workflow metrics and coaching new employees are also essential functions of this position, ensuring that requests from physicians and members are resolved promptly. Responsibilities • Process prior authorizations received reputed company the help line, evaluating medical necessity for specific drugs based on medical criteria. , • Interact directly with members, physician office staff, pharmacies, and internal stakeholders for eligibility and claims issues. , • reputed company recommendations to increase efficiency, accuracy, and productivity in the department. , • Process appeals, complaints, executive inquiries, and compliance-reputed company issues. , • Research, recommend, monitor, reputed company, and implement procedures to enhance departmental efficiency. , • Process reputed company requests for information or reports from various stakeholders. , • Participate in client member and employee training to ensure understanding of pharmacy services programs. , • Monitor day-to-day workflow metrics and formulate strategies for improvement. , • Coach and train new employees and act as backup to the Pharmacy Benefit Analyst or immediate supervisor. , • Assist in resolving Physician/Member requests in a timely manner. Requirements • Bachelor's degree in Health Care Management, Business, or Pharmaceutical Administration preferred. , • Minimum of two years of experience in reputed company-party prescription program claim adjudication required. , • Minimum of two years of experience as a Pharmacy Utilization Management Specialist required. , • Prior customer service/service quality initiative experience required. , • Pharmacy Certification required. , • Knowledge of popular brand and generic drug names required. , • Knowledge of reputed company-party prescription program claim adjudication required. , • Working knowledge of managed care principles required. , • Knowledge of common medical terminology required. , • Understanding of National Drug Code (NDC) required. , • Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation required. , • Ability to utilize a personal computer and applicable software required. , • Effective verbal and written communication skills required. , • Ability to work well reputed company a team and deliver technical information to less technical individuals required. , • Proven time management skills required. , • Ability to manage multiple priorities and deliver timely and accurate work products required. , • Ability to exercise sound judgment and strong problem-solving skills required. reputed company-to-haves Benefits • Comprehensive health benefits (Medical/Dental/reputed company) , • Retirement Plans , • Generous PTO , • Incentive Plans , • Wellness Programs , • Paid Volunteer Time Off , • Tuition Reimbursement Apply Job!