Job Description

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, or Nevada.

Position Title: Pharmacy Benefit Specialist Lead

Department: Pharmacy

Title of Manager: Pharmacy Benefit Operations Supervisor

Supervises: Non-supervisory position

Exemption Status: Non-Exempt

Requisition ID: 23552

Pay and Benefits: Estimated hiring range $45,850 - $55,500, 10% lead pay, 5% bonus target, full benefits. To learn more about our benefits, please visit www.careoregon.org/about-us/careers/benefits

Job Summary

This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. This is an advanced level support position, requiring Pharmacy Technician Certification, as well as leadership to pharmacy team members. Core responsibilities include training, coaching, and monitoring staff work and assisting leadership with department processes, as well as customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project leadership or participation.

Essential Responsibilities

Leadership

• Provide leadership for a team in a support of team direction and goals.
• Provide input into staffing needs; assist in recruiting, hiring and leading a team to meet work needs, using an equity, diversity, and inclusion lens.
• Participate in organizing, scheduling, monitoring and improving work; help ensure employees have information to meet job expectations and have coverage during absences.
• Contribute to the development, communication, and oversight of a team and individual goals.
• Train, lead, and coach employees; may facilitate team meetings.
• Incorporate guidance from CareOregon equity tools into people leadership.
• Help monitor employee adherence to department and organizational standards, policies, and procedures.
• Assist in evaluating employee performance, providing feedback to support success, recognizing strong performance, and addressing performance gaps and accountability (corrective action).
• Perform lead tasks in collaboration with Human Resources as needed.

Customer Service and Claims Processing

• Communicate in a professional and respectful manner.
• Maintain confidentiality within HIPAA regulations and function on \xe2\x80\x9cneed to know\xe2\x80\x9d principles.
• Respond to escalated pharmacy benefit inquires in an accurate and timely manner to members, members\' representatives, providers, and CareOregon staff.
• Educate members, providers, pharmacies and CareOregon staff about the CareOregon formularies and pharmacy benefit policies.
• Document all customer service activities according to organization requirements.
• Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims adjudication issues as it pertains to the CareOregon pharmacy benefits and drugs covered under the major medical benefit.
• Follow policies and procedures to determine a resolution to pharmacy claims processing requests or triage to other CareOregon staff for assistance.

Data Entry and Clerical Support

• Sort incoming faxes and distribute according to assignments.
• Maintain files according to unit protocols.
• Assist data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
• Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.

Prior Authorizations (PA) and Formulary Exceptions

• Verify member\'s plan eligibility and applicable benefit for drug coverage.
• Review member\'s medication and eligibility history, load authorization in claim adjudication platform(s).
• Assist members and providers with the PA, formulary exception and coverage determination process.
• Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions.
• Perform prior authorization reviews with pharmacist oversight.

Appeals and Grievances

• Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff.
• Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
• Complete pharmacy appeals and notify members and providers of outcome.
• Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.

Project Coordination

Under the supervision of a pharmacist and/or the operations supervisor, perform and/or lead pharmacy benefit projects, including, but not limited to accelerated process improvement teams or PDSA cycles, cost saving initiative projects, benefit implementation/changes, member/provider/pharmacy outreach, assist in training new hire staff, and create and upkeep standard operating procedures.

Organizational Responsibilities

• Ability to organize, plan, and prioritize daily workflow and projects within time constraints for self and others
• Ability to lead in an environment with diverse individuals and groups
• Perform work in alignment with the organization\'s mission, vision, and values.
• Support the organization\'s commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
• Strive to meet annual business goals in support the organization\'s strategic goals.
• Adhere to the organization\'s policies, procedures, and other relevant compliance needs.
• Perform other duties as needed.

Knowledge, Skills and Abilities Required

Expert knowledge in some or all of the following areas:

Technical

• Excellent knowledge of medical and pharmaceutical terminology
• Excellent understanding of managed care, Medicare, and Oregon Health Plan concepts, including the ability to train and coach others on this information
• Advanced skills in PBM software programs necessary to perform job responsibilities
• Proficient with Microsoft Office Products and general computer literacy
• Ability to participate in the development and monitoring of policies and procedures in performing job responsibilities.

Communication

• Excellent listening, verbal, and written communication skills
• Ability to exercise a high degree of professionalism
• Advanced ability to network and utilize internal and external resources
• Ability to articulate policies and instructions

Cognitive and Others

• Ability to focus on and comprehend information
• Ability to learn new skills and abilities
• Ability to assess a situation and seek or determine appropriate resolution
• Ability to accept managerial direction and feedback
• Ability to tolerate and manage stress
• Results and service oriented
• Ability to be flexible and adaptable
• Ability to organize, plan, and prioritize daily workflow and projects within time constraints for self and others
• Ability to work in an environment with diverse individuals and groups
• Ability to work independently with minimal supervision
• Ability to lead in an environment with diverse individuals and groups

Physical Skills and Abilities

Lifting/Carrying up to 0 Pounds

Pushing/Pulling up to 0 Pounds

Pinching/Retrieving Small Objects

Crouching/Crawling

Reaching

Climbing Stairs

Repetitive Finger/Wrist/Elbow/

Shoulder/Neck Movement

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

Standing

Walking

Sitting

Bending

Seeing

Reading

Hearing

Speaking Clearly

0 hours/day

0 hours/day

0 hours/day

0 hours/day

More than 6 hours/day

More than 6 hours/day

3-6 hours/day

3-6 hours/day

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

Required:

• Minimum 3 years\' related experience, including 2 years as a Pharmacy Benefit Specialist or similar role
• Pharmacy Technician Certification (PTCB or ExCPT)

Preferred:

• Experience with people and/or project leadership
• Minimum 1 year\' experience as a Pharmacy Benefit Specialist with CareOregon

Working Conditions

\xe2\x98\x92 Inside/office \xe2\x98\x90 Clinics/health facilities \xe2\x98\x90 Member homes

\xe2\x98\x90 Other

• Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee\'s personal vehicle, local transit, or other means of transportation may be used.
• Equipment: General office equipment
• Hazards: n/a

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

CareOregon