Pharmacy Specialist I

Horizon Blue Cross Blue Shield of New Jersey Horizon BCBSNJ empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. We strive to maintain an innovative and inclusive environment that allows employees to thrive. When our employees succeed, the Company succeeds. About the Role This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects. This position must ensure performance is in compliance with organizational or departmental goals and regulatory requirements. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs based on clinical criteria. What You\'ll Do Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues. Engagement with physicians and pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design. Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination. Satisfy all departmental customer service quality metrics while ensuring that all regulatory turnaround times are consistently satisfied. Process complaints, appeals, grievances, executive inquiries and compliance related issues. Identify potential fraud, waste, and abuse through interactions with members and providers and make internal referrals as necessary. Provide recommendations to increase efficiency, accuracy and productivity in the department. Process ad hoc information or report requests from stakeholders. Be accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows. Assist in the day-to-day operations of the pharmacy department and the Medication Therapy Management program. Provide support to various clinical programs within the pharmacy department. What You Bring Education/Experience: High School Diploma/GED required Minimum of two (2) years experience as a Pharmacy technician Preference for minimum of two (2) years experience in third party prescription program claim adjudication Requires prior customer service/service quality initiative experience Additional licensing, certifications, registrations Requires National Pharmacy Technician Certification (PTCB or ExCPT) In lieu of the Pharmacy Tech Certification, a minimum of 5 years' experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM is required Knowledge Knowledge of popular brand and generic drug names Knowledge of third party prescription program claim adjudication Working knowledge of managed care principles Knowledge of common medical terminology Understanding of National Drug Code (NDC) Knowledge of New Jersey Board of Pharmacy regulations and state/federal controlled substances regulations Skills and Abilities Proficient with personal computing and applicable software Effective verbal and written communication skills; ability to work well within a team and convey highly technical information to less technical individuals Professional and ethical business practices; adherence to company standards and commitment to development Strong time management; ability to manage multiple priorities, deliver timely and accurate work with a customer service focus Ability to work in a production-focused environment Sound judgment and strong problem-solving skills Ability to ask probing questions and obtain thorough and relevant information Why Horizon? At Horizon, you\'ll do meaningful work that directly improves lives while being supported by a mission-driven organization that values expertise, collaboration, and growth. If you are passionate about making an impact, we would love to hear from you! Salary Range $44,600 - $59,745 This compensation range is specific to the job level and takes into account various factors including education, experience, licensure, certifications, location, and internal equity. Horizon provides a comprehensive compensation and benefits package including: Comprehensive health benefits (Medical/Dental/Vision) Retirement plans Generous PTO Incentive plans Wellness programs Paid Volunteer Time Off Tution Reimbursement Disclaimer Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware. This job summary indicates the general nature and level of work performed and is not a comprehensive inventory of all duties, responsibilities, and qualifications. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability, and any other protected class as required by law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr Horizon Blue Cross Blue Shield of New Jersey