Pharmacy Operations Representative

Job Description

The Pharmacy Operations Analyst is responsible for being the primary contact for our providers to obtain authorization for retail pharmacy, home infusion and medical utilization management requests. These requests are received via fax, phone and web. Key Responsibilities: ? Receive, process, and archive provider's retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria ? 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 ? Analyze and interpret high level medical data and accurately data entry information according to NCQA guidelines ? Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MHK and other systems via fax or telephone ? Communicate determinations to providers via incoming and outgoing telephone calls ? Process pharmacy authorizations utilizing PBM real time on line 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, Medical Policy interpretation, and plan design interpretation ? Support Medicare Part D and understanding of CMS guidelines Requirements: ? 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 Preferred Qualifications: ? Minimum of a High School diploma required ? Associate or Bachelor's degree preferred ? Proficiency in MHK and CVS PBM Systems ? Experience in a Windows environment preferred ? Previous experience in a managed care environment preferred ? Previous pharmacy experience preferred

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