Job Information
WellSense Pharmacy Operations Specialist in United States
Pharmacy Operations Specialist
WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.
Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294389)
It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Job Summary:
Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed.
Our Investment in You:
Full-time remote work
Competitive salaries
Excellent benefits
Key Functions/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:
Education:
Minimum of a High School diploma or equivalent required
Associate or Bachelor’s degree preferred
Experience:
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
Competencies, Skills, and Attributes:
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
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees
Apply now (https://jobs.silkroad.com/BMCHP/Careers/Apply/MultiForm/294389)
Important info on employment offer scams:
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not reach out to individuals via text, we do not ask or require downloads of any applications, or “apps”, and applicant screenings, interviews and job offers are not conducted over text messages or social media platforms. We do not ask individuals to purchase equipment for, or prior to employment. To avoid becoming a victim of an employment offer scam, please followthese tips from the FTC (https://consumer.ftc.gov/consumer-alerts/2023/01/looking-job-scammers-might-be-looking-you?utm_source=govdelivery) .