Job Summary :
Assists members in navigating their pharmacy benefit(s). Helps troubleshoot rejected claims, provides formulary information, coordinates care between the pharmacy and medical benefits, and identifies opportunities for both member and health plan cost savings.
Job Requirements :
Education and Work Experience :
- High School Education / GED or equivalent : Required
- Two years experience with pharmacy claims billing or processing in the retail setting : Preferred
- One year managed care experience : Preferred
Licenses / Certifications :
State Pharmacy Techncian license : Required in CAFacility Specific License / Certifications :
State Pharmacy Technician (PTC) : RequiredEssential Functions :
Answers phone calls that are transferred to the health plan pharmacy department. Collects information, researches issues, educates the member about their options, and documents all activities clearly and concisely in care management software.Reviews daily rejected claims reports. Identifies members for outreach, creates outreach plans for pharmacist review and reaches out to members as directed by a health plan pharmacist. Refers all clinical questions to the health plan pharmacist. Works with eligibility and health plan data departments to troubleshoot eligibility related pharmacy issues.Reviews pharmacy ranking reports. Summarizes pharmacy use by channel (in-house, community partner, mail-order pharmacies).Runs pharmacy profile reports and uploads them into care management software. Creates and / or reviews reports from the pharmacy benefit manager portal.Follows all compliance policies and procedures, applicable laws and regulation adapted by AH including : Fraud Awareness, HIPAA, use of organizational approved web sites.Performs other job-related duties as assigned.Organizational Requirements :
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https : / / / careers / everify / for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.