CareOregon
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Pharmacy Benefit Specialist II
role at
CareOregon
This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation.
Estimated Hiring Range:
$25.42 - $31.07 Bonus Target:
5% annual
Essential Responsibilities Customer Service and Claims Processing
Communicate in a professional and respectful manner.
Maintain confidentiality within HIPAA regulations and function on “need to know” principles.
Respond to drug coverage inquiries in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff.
Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies.
Document all customer service activities according to organization requirements.
Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit.
Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance.
Data Entry and Clerical Support
Sort incoming faxes and distribute according to assignments.
Maintain files according to unit protocols.
Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
Clerical assistance for pharmacy projects, including distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.
Prior Authorizations (PA) and Formulary Exceptions
Verify member’s plan eligibility and applicable benefit for drug coverage.
Review member’s medication and eligibility history, load authorization in claim adjudication platform(s).
Assist members and providers with the PA, formulary exception and coverage determination process.
Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions.
Perform prior authorization reviews with pharmacist oversight.
Appeals and Grievances
Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff.
Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
Complete pharmacy appeals and notify members and providers of outcome.
Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.
Project Coordination
Under the supervision of a pharmacist and/or the operations supervisor, assist with pharmacy benefit projects including process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach.
Required Experience and/or Education
Minimum 2 years work experience on a pharmacy team (i.e., retail, long‑term care, or hospital) or 2 years’ experience in a health insurance plan.
Minimum 1 year experience with managed care and/or pharmacy benefit management.
Preferred (Priority will be given to candidates possessing experience with the preferred skills listed below)
Pharmacy Technician Certification (CPhT)
Experience with daily calls with Providers and Members
Willing to work rotation schedule 3‑4 times a year.
Knowledge, Skills, and Abilities Required
Advanced knowledge of medical and pharmaceutical terminology.
Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Proficient with Microsoft Office Products and general computer literacy.
Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities.
Advanced listening, verbal, and written communication skills.
Ability to exercise professionalism, work independently, and manage stress.
Results and service oriented, flexible and adaptable.
Ability to organize, plan, and prioritize daily workflow and projects within time constraints.
Ability to learn new skills and abilities; to assess situations and determine appropriate resolution.
Working Conditions Work Environment: Indoor/Office. Member/Patient Facing: No. Hazards may include physical and ergonomic risks. Equipment: General office equipment. Travel: Occasional required or optional travel outside of the workplace. Work Location: Work from home.
Total Rewards Program Competitive pay, bonus opportunity, and a comprehensive benefits package. Eligible employees qualify for benefits beginning on the first of the month following their start date. Benefits include medical, dental, vision, life, AD&D, disability, health savings account, flexible spending account, employee assistance program, wellness program, discounts, retirement plan with employer contributions, PTO, paid state sick time, paid holidays, and more.
Equal Opportunity Employer CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job‑related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender identity, gender expression, genetic information, age, veteran status, marital status, or disability. The organization will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of the organization.
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Pharmacy Benefit Specialist II
role at
CareOregon
This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation.
Estimated Hiring Range:
$25.42 - $31.07 Bonus Target:
5% annual
Essential Responsibilities Customer Service and Claims Processing
Communicate in a professional and respectful manner.
Maintain confidentiality within HIPAA regulations and function on “need to know” principles.
Respond to drug coverage inquiries in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff.
Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies.
Document all customer service activities according to organization requirements.
Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit.
Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance.
Data Entry and Clerical Support
Sort incoming faxes and distribute according to assignments.
Maintain files according to unit protocols.
Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
Clerical assistance for pharmacy projects, including distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.
Prior Authorizations (PA) and Formulary Exceptions
Verify member’s plan eligibility and applicable benefit for drug coverage.
Review member’s medication and eligibility history, load authorization in claim adjudication platform(s).
Assist members and providers with the PA, formulary exception and coverage determination process.
Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions.
Perform prior authorization reviews with pharmacist oversight.
Appeals and Grievances
Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff.
Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
Complete pharmacy appeals and notify members and providers of outcome.
Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.
Project Coordination
Under the supervision of a pharmacist and/or the operations supervisor, assist with pharmacy benefit projects including process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach.
Required Experience and/or Education
Minimum 2 years work experience on a pharmacy team (i.e., retail, long‑term care, or hospital) or 2 years’ experience in a health insurance plan.
Minimum 1 year experience with managed care and/or pharmacy benefit management.
Preferred (Priority will be given to candidates possessing experience with the preferred skills listed below)
Pharmacy Technician Certification (CPhT)
Experience with daily calls with Providers and Members
Willing to work rotation schedule 3‑4 times a year.
Knowledge, Skills, and Abilities Required
Advanced knowledge of medical and pharmaceutical terminology.
Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Proficient with Microsoft Office Products and general computer literacy.
Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities.
Advanced listening, verbal, and written communication skills.
Ability to exercise professionalism, work independently, and manage stress.
Results and service oriented, flexible and adaptable.
Ability to organize, plan, and prioritize daily workflow and projects within time constraints.
Ability to learn new skills and abilities; to assess situations and determine appropriate resolution.
Working Conditions Work Environment: Indoor/Office. Member/Patient Facing: No. Hazards may include physical and ergonomic risks. Equipment: General office equipment. Travel: Occasional required or optional travel outside of the workplace. Work Location: Work from home.
Total Rewards Program Competitive pay, bonus opportunity, and a comprehensive benefits package. Eligible employees qualify for benefits beginning on the first of the month following their start date. Benefits include medical, dental, vision, life, AD&D, disability, health savings account, flexible spending account, employee assistance program, wellness program, discounts, retirement plan with employer contributions, PTO, paid state sick time, paid holidays, and more.
Equal Opportunity Employer CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job‑related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender identity, gender expression, genetic information, age, veteran status, marital status, or disability. The organization will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of the organization.
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