The posting
Its 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.
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 members 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
Education
Qualifications:
- Minimum of a High School diploma or equivalent required. Associate or Bachelors 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 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
- WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.
