Pharmacy Operations Representative Job at Blue Cross Blue Shield of Massachusetts
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Position Summary:
The Pharmacy Operations Representative is responsible for 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. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
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
Other responsibilities as needed
***This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster.
Qualification (Knowledge, skills, and abilities):
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.
Education/Relevant Experience:
Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
Proficiency in MCPS and Foundation 14 preferred
Experience in a Windows environment preferred
Previous experience in a managed care environment preferred
Previous pharmacy experience preferred
Position Summary: The Pharmacy Operations Representative is responsible for 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. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
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
Other responsibilities as needed
***This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster.
Qualification (Knowledge, skills, and abilities):
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.
Education/Relevant Experience:
Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
Proficiency in MCPS and Foundation 14 preferred
Experience in a Windows environment preferred
Previous experience in a managed care environment preferred
Previous pharmacy experience preferred
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
Location Hingham Time Type Full time
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).
Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement. Your offer of employment is dependent upon either being fully vaccinated for COVID-19 or an accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.
Please Note :
caminobluff.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, caminobluff.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.
Position Summary:
The Pharmacy Operations Representative is responsible for 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. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
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
Other responsibilities as needed
***This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster.
Qualification (Knowledge, skills, and abilities):
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.
Education/Relevant Experience:
Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
Proficiency in MCPS and Foundation 14 preferred
Experience in a Windows environment preferred
Previous experience in a managed care environment preferred
Previous pharmacy experience preferred
Position Summary: The Pharmacy Operations Representative is responsible for 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. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
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
Other responsibilities as needed
***This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster.
Qualification (Knowledge, skills, and abilities):
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.
Education/Relevant Experience:
Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
Proficiency in MCPS and Foundation 14 preferred
Experience in a Windows environment preferred
Previous experience in a managed care environment preferred
Previous pharmacy experience preferred
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
Location Hingham Time Type Full time
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).
Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement. Your offer of employment is dependent upon either being fully vaccinated for COVID-19 or an accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.
Please Note :
caminobluff.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, caminobluff.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.