- Handles calls and correspondence regarding pharmacy issues from providers/physicians and members. Identifies and/or responds to inquiries, benefit payments, complaints, dissatisfaction, grievances and claim issues. Document calls in inquiry tracking system. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Facilitates problem resolution and acts as customers advocate.
- Reviews daily work activity report to self-monitor performance and productivity standards. Identifies deficiencies/problems and adjust behavior and work activities as appropriate. Follows internal process and procedures to ensure activities are handled in accordance with departmental and company policies/procedures.
- Performs initial research of pharmacy issues. Reconciles plan information utilizing department-generated procedures and reference materials. Appropriately escalates claims outside knowledge and/or clinical scope to higher-level call center staff or pharmacist for review. Utilizes internal Pharmacy systems to update, modify and extract member information.
- Assists network pharmacist in processing prescription claims. Reviews claims for accuracy and adherence to contract guidelines. Reviews and authorizes appropriate faxed medication requests from institutional/long term facilities and maintains consistent contact with all facilities to assure protocols are maintained.
- Assists with entering prior authorizations when required; provides follow up assistance for prior authorization requests, follow up with request from physicians for denial letters, provides assistance in gathering historical claim information as required. Provides Level II Pharmacy Technician, Supervisor and/or Pharmacist with background data needed for claim review, appeals and grievances.
- Discriminates between routine and significant matters; apprises management of issues which can negatively affect service and business. Identifies provider/physician/member issues and refers to appropriate departments. Suspend inquiries forwarded to pharmacists or other departments and follows through to ensure timely resolution.
- 2 years Pharmacy Technician experience in a healthcare, long term care or retail environment.
- Minimum 35 wpm typing.
All your information will be kept confidential according to EEO guidelines.
