801 Massachusetts Ave. Boston, MA 02119 , 1st floor
Boston,
MA
02119
US
Posted: 11/16/2023
2023-11-16
2024-01-03
Employment Type:
Contract
Job Category: Administrative
Job Number: 581851
Is job remote?: Yes
Country: United States
Job Description
Operations Specialist: Healthcare
3-month contract, extension possible
Location: Remote (EST hours likely)
$20-22/hr
Must Haves:
- HS diploma or equivalent education
- Two or more years of experience in a professional or pharmacy setting
Preferred:
- College degree
- Previous experience in a managed care environment preferred
- Prior customer service experience preferred
Job Summary/Description:
Responsibilities:
- Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements.
- Properly apply clinical policy criteria to the review of prior authorization requests
- 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
- Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements
- Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications
- Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
- Provide pharmacy-related customer service to both internal and external parties.
- Process pharmacy authorizations utilizing PBM real time online 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, Pharmacy Policy interpretation, and plan design interpretation.
- Other responsibilities as needed
Qualifications/Skills:
- Minimum of a High School diploma or equivalent required. Associate or Bachelor’s degree preferred
- Two or more years of experience in a professional or pharmacy setting
- Previous experience in a managed care environment preferred
- Prior customer service experience preferred
- 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
Share This Job:
Login to save this search and get notified of similar positions.
