Member Advocate

Interact with members, pharmacies, and physicians to provide accurate information and support related to pharmacy benefits. Handle inquiries by phone, chat, and email. Assist with benefit questions, claim issues, medication access challenges, and pharmacy benefit experience. Provide assistance regarding formulary coverage, copays, prior authorizations, and medication access. Support pharmacies with claim processing questions or issues. Work with providers on prior authorizations and drug coverage information. Identify claims requiring action, initiate outbound outreach, and resolve issues efficiently. Handle complex or sensitive cases and follow escalation pathways when needed. Verify required data elements and adhere to HIPAA and internal privacy policies. Navigate software, applications, and PBM tools. Document interactions in the ticketing system. Participate in call quality reviews, team discussions, and activities. Collaborate with Clinical, Account Management, Operations, and other internal departments to research and resolve complex issues. Requirements High school diploma or equivalent required. Previous experience in pharmacy benefit management (PBM) is strongly preferred; pharmacy technician, healthcare, insurance, customer service, or call center experience highly valued. Member-focused mindset with a passion for improving the member experience. Highly effective verbal and written communication skills. Demonstrates teamwork by collaborating effectively with peers and cross-functional teams to support member needs. Strong computer skills, including Microsoft Office, with the ability to quickly learn new systems and technology. Ability to multitask, manage time efficiently, and stay organized in a fast-paced, high-volume environment. Excellent active listening, problem solving, and critical thinking skills. Core Competencies Demonstrates expertise in pharmacy benefit management, including handling inquiries related to formulary coverage, prior authorizations, and medication access. Strong communication and problem-solving skills are essential for effectively collaborating with members, pharmacies, and healthcare providers. Highest-signal resume keywords Pharmacy Benefit Management (PBM) Verbal And Written Communication Skills Microsoft Office Proficiency Active Listening Problem Solving ATS Optimization Keywords Hard Skills Formulary Coverage Prior Authorizations Claim Processing Medication Access Data Verification Soft Skills Member-Focused Mindset Team Collaboration Time Management Organizational Skills Critical Thinking Industry Keywords HIPAA Compliance Healthcare Insurance Customer Service Call Center Experience Tools & Technologies Ticketing System PBM Tools Software Applications #J-18808-Ljbffr