The posting
Summary
Responsible for setting up cases for pharmacy authorization requests and performing pharmacy reviews as per established criteria. Maintains the timely, complete, and accurate processing of authorization requests by interfacing with internal and external customers and the Pharmacy Benefit Manager (PBM) to resolve issues that may arise in the provision of pharmacy services. Processes determination letters and documents decisions using indicated protocol or clinical guidelines. Participates in quality control and/or quality improvement activities.
Description
Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
Responsible for setting up cases for pharmacy authorization requests and performing pharmacy reviews as per established criteria. Maintains the timely, complete, and accurate processing of authorization requests by interfacing with internal and external customers and the Pharmacy Benefit Manager (PBM) to resolve issues that may arise in the provision of pharmacy services. Processes determination letters and documents decisions using indicated protocol or clinical guidelines. Participates in quality control and/or quality improvement activities.
Location:
This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift between the hours of 7am - 7pm. This position is eligible for hybrid work after the training period. This role is located at 4101 Percival Road, Columbia, SC 29229. There is the expectation of rotating weekends and holidays as well.
What You’ll Do:
- Receives and builds cases in the various applications for pharmacy authorization requests. Under Pharmacist guidance and per company policies/guidelines and established criteria sets, reviews, evaluates and authorizes approval of pharmacy requests. Requests additional information from providers including confidential medical history and prior drug therapy, in order to properly evaluate the request. Determines appropriateness for medications. Processes determination letters and communicates decision to providers and/or members ensuring timeliness and accuracy. Researches, resolves and documents outcomes in pharmacy system. Communicates selected authorization criteria, pharmacy benefit coverage, formulary alternatives and/or Pharmacy Management program policies and procedures to pharmacy providers, members and internal contacts. Conducts research necessary to make thorough/accurate basis for each determination made.
- Loads authorization into the system and ensures the clinical determination is documented accurately into the system for all levels of care. Utilizes allocated resources to back up review determinations. Completes all assigned work within established timeliness guidelines.
- Identifies and makes referrals to appropriate staff (Pharmacist, Case Manager, Preventive Services, Subrogation, Quality of Care Referrals, etc.). Escalates requests to Pharmacist when request requires extensive clinical review.
- Establishes and maintains effective relationships with providers, members and internal contacts. Responds appropriately to inquiries received from providers, members and internal contacts. Researches and resolves issues using the appropriate reference material.
- Participates in quality control and/or quality improvement activities in support of the corporate and team-based objectives. Participates in all Required Licenses and Certificates.
To Qualify For This Position, You'll Need The Following:
- Required Education: High School Diploma or equivalent
- Required Work Experience: 3 years pharmacy technician experience.
- Required Skills and Abilities: Working knowledge of pharmaceutical claims, language, drug usage and generic substitution practices. Good judgment. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Attention to detail and the ability to handle multiple demands and balance multiple priorities in a fast-paced environment. Ability to remain in a stationary position and operate a computer.
- Required Software and Other Tools: Microsoft Office.
- Required Licenses and Certificates: Registered Pharmacy Technician with the applicable state Board of Pharmacy and Certified Pharmacy Technician.
We Prefer That You Have The Following:
- Preferred Work Experience: 3 years-pharmacy experience in managed care setting or PBM.
Our Comprehensive Benefits Package Includes The Following:
We offer our employees great benefits and rewards. You will be eligible to participate in our benefits program the first of the month following 28 days of employment.
- Subsidized health plans, dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
What To Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.
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