Representative, Pharmacy

Pharmacy Call Center Representative

Provides customer service support for inbound/outbound pharmacy calls from members, providers, and pharmacies. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties Handles and records inbound/outbound pharmacy calls from members, providers and pharmacies in accordance with departmental policies, state regulations, National Committee of Quality Assurance (NCQA) guidelines, and Centers for Medicare and Medicaid Services (CMS) standards. Provides coordination and processing of pharmacy prior authorization requests and/or appeals. Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other necessary information to providers, members and pharmacies. Assists with clerical tasks and other day-to-day pharmacy call center operations as delegated. Effectively communicates plan benefit information, including but not limited to: formulary information, copay amounts, pharmacy location services and prior authorization outcomes. Assists members and providers with initiating verbal and written coverage determinations and appeals. Records calls accurately within the pharmacy call tracking system. Maintains established pharmacy call quality and quantity standards. Interacts with appropriate primary care providers to ensure member registry is current and accurate. Supports pharmacists with completion of comprehensive medication reviews (CMRs) through pre-work up to case preparation. Proactively identifies ways to improve pharmacy call center member relations. Required Qualifications At least 1 year related experience, including call center or customer service experience, or equivalent combination of relevant education and experience. Excellent customer service skills. Ability to work independently when assigned special projects, such as pill box requests, case management referrals, over the counter (OTC) requests, etc. Ability to multi-task applications while speaking with members. Ability to develop and maintain positive and effective work relationships with coworkers, clients, members, providers, regulatory agencies, and vendors. Ability to meet established deadlines. Ability to function independently and manage multiple projects. Excellent verbal and written communication skills, including excellent phone etiquette. Microsoft Office suite (including Excel), and applicable software program(s) proficiency. Preferred Qualifications Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. Health care industry experience.