Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the BMCHP pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed. 

KEY FUNCTIONS/RESPONSIBILITIES:

• 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

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 able to multitask and be results oriented

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience