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  Understands the intricacies of prescription drug benefits and how they adjudicate (NCPDP reject codes)
• Must have the ability to multi-task and perform multiple functions throughout the day to support PBM operations (Review prior authorizations, taking inbound/outbound calls, reviewing reports, and resolving failed claims reprocessing)
• Receives, reviews, and provides accurate and timely data entry of prescription prior authorization requests from contracted providers via telephone, fax, email, or surface mail
• Conducts outreach calls to providers and participants to obtain necessary clinical criteria forms/progress notes
• Communicates and understands drug formulary guidelines, drug formulary alternatives, prior authorization criteria, and eligibility issue to participants, providers, pharmacies
• Understands plan benefit design unique to each plan, including copays, copay assistance, and pharmacy network
• Provides timely responses and resolution regarding escalated participant issues to external vendors and internal UHH department (health advocates/member services). Resolution requires assisting participants and providers in understanding and utilizing pharmacy benefits
• Researches and interprets claims issues on daily reject report to assists pharmacies in resolving obstacles for a prior authorization related to medication (Claim dollar, refill to soon, vacation overrides, pricing errors, max dose, DUR)
• Assists with adding new or updating existing prior authorization criteria in the software system (PA Hub/ Agadia). This includes adding automatic decision scenarios and authorization time frames
• Conducts analytic functions in excel (formulas: VLOOKUP, SUM, AVERAGES, creating tables, SORT, FILTER) to prepare files for mail merges that assist with developing communications to participants
• Communicates plan benefit/formulary changes to participants and providers through outreach calls and/or sending faxes/letters
• Supports ongoing clinical programs including assistance with development, implementation, and ongoing monitoring. This includes outreach calls to members and providers for clinical data, tracking metrics, and monitoring of claims history
• Assists with ongoing pharmacy department projects and programs
• Set goals and achieve measurable results
• Contributes innovative ideas to help achieve department goals (Service level, % Voicemail, % Abandoned, # Unresolved faxes, Average speed of answer)
• Provides customer service support to members, and identified, reports, and escalates any member complaints or issues to team lead and/or manager
• Assists members with manufacturer or other assistance programs
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

• 2-4 years of working knowledge and experience as a pharmacy technician
• Intermediate level Microsoft Excel skills (VLOOKUP, Sum, Average, Sort, Filter, create tables) preferred
• Intermediate level Microsoft Office skills (Outlook, PowerPoint, Word) preferred
• 2-4 years of patient, provider, and pharmacy customer service experience preferred
• 2-4 years of working knowledge and experience in prior authorization within a pharmacy benefit managed care required (ex; PA Hub-Agadia)
• 2-4 years of working knowledge and experience with third party rejects and resolving rejected claims
• 2-4 years of experience with third party medical/prescription payment and/or claims adjudication systems (Rx Claims)

• High School diploma or GED
• Required: Certified Pharmacy Technician (CPhT) License

• Ability to work 11am~7pm (CT)
• Preferred fluency (speak and write) in Spanish
• Communication skills (written and verbal)
• Detail oriented, analytical and organizational skills
• Customer focus with commitment to providing excellent customer service
• Ability to identify and interpret drug names, uses, and doses

We reward great work with great benefits. The benefits we offer include but are not limited to: Medical/Dental/Vision benefits, Paid Time-Off (PTO), Paid Holidays, Short & Long-Term disability, Life & Accidental death, Pension, 401(k), Tuition Assistance, Employee Assistance Program (EAP), Healthcare Flexible Spending Accounts (HFSA) and Dependent Care Flexible Spending Account (DCFSA).