CareOregon
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Pharmacy Benefit Specialist II
role at
CareOregon .
This position supports CareOregon members, their providers, and pharmacies with 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:
$25,420 - $31,070 per year
Bonus Target:
5% annual on SIP Target
Essential Responsibilities Customer Service and Claims Processing
Communicate professionally and respectfully.
Maintain confidentiality under HIPAA and need-to-know principles.
Respond to drug coverage inquiries accurately and timely to members, representatives, providers, and CareOregon staff.
Educate stakeholders about CareOregon formularies and pharmacy benefit policies.
Document all customer service activities per organizational requirements.
Answer claims processing questions related to CareOregon pharmacy benefits under the major medical benefit.
Determine resolution for pharmacy claims adjudication issues or triage to appropriate CareOregon staff.
Data Entry and Clerical Support
Sort incoming faxes and distribute per assignments.
Maintain files per unit protocols.
Enter data into claims processing systems, document management systems, databases, and spreadsheets.
Assist with pharmacy projects, including distribution of education materials, letters & mailings, and reports.
Prior Authorizations (PA) and Formulary Exceptions
Verify member eligibility and applicable benefit for drug coverage.
Review member medication and eligibility history; load authorization in the claims adjudication platform.
Assist members and providers with PA, formulary exception, and coverage determination.
Facilitate resolution for PA and formulary exception requests; notify stakeholders of decisions.
Perform PA reviews with pharmacist oversight.
Appeals and Grievances
Explain pharmacy appeal and grievance provisions and processes to stakeholders.
Collect data for appeals & reconsiderations; prepare appeals for review by Pharmacists & Medical Directors.
Complete and notify stakeholders of appeal outcomes.
Assist coordination of pharmacy benefit appeals and grievances with relevant teams.
Project Coordination
Assist with pharmacy benefit projects under pharmacist and/or operations supervisor guidance, including process improvements, cost-saving initiatives, benefit implementation/changes, and member/provider/pharmacy outreach.
Required Experience and Education
Minimum 2 years in a pharmacy team (retail, long‑term care, or hospital) or 2 years in a health insurance plan.
Minimum 1 year experience with managed care and/or pharmacy benefit management.
Preferred Qualifications (Priority)
Pharmacy Technician Certification (CPhT).
Experience with daily calls with providers and members.
Willingness to work a rotation schedule 3–4 times a year.
Knowledge, Skills, and Abilities
Advanced knowledge of medical and pharmaceutical terminology.
Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Proficient with Microsoft Office and CareOregon/PBM software.
Excellent verbal and written communication; active listening.
Ability to learn and navigate new systems, policies, and procedures.
Strong problem‑solving, organization, and prioritization skills.
Teamwork with diverse stakeholders and independent work under minimal supervision.
Stress management and professional conduct in all interactions.
Working Conditions Work Environment: Office/Indoor; occasional travel; flexible work schedule including work from home.
Physical Demands: General office equipment; may require repetitive finger and wrist movement; ability to speak and hear clearly for extended periods.
Benefits and Compensation Competitive salary with bonus opportunity, comprehensive medical, dental, vision, life, and AD&D insurance; retirement plan with employer contributions; PTO, paid state sick leave, and additional perks. Benefits-eligible employees qualify beginning on the first of the month after their start date.
Equal Opportunity Employer CareOregon is an equal opportunity employer. We select the best candidate for the job based on qualifications, regardless of race, color, religion, sexual orientation, gender identity, national origin, or disability. Reasonable accommodations will be provided for qualified individuals with disabilities.
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Pharmacy Benefit Specialist II
role at
CareOregon .
This position supports CareOregon members, their providers, and pharmacies with 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:
$25,420 - $31,070 per year
Bonus Target:
5% annual on SIP Target
Essential Responsibilities Customer Service and Claims Processing
Communicate professionally and respectfully.
Maintain confidentiality under HIPAA and need-to-know principles.
Respond to drug coverage inquiries accurately and timely to members, representatives, providers, and CareOregon staff.
Educate stakeholders about CareOregon formularies and pharmacy benefit policies.
Document all customer service activities per organizational requirements.
Answer claims processing questions related to CareOregon pharmacy benefits under the major medical benefit.
Determine resolution for pharmacy claims adjudication issues or triage to appropriate CareOregon staff.
Data Entry and Clerical Support
Sort incoming faxes and distribute per assignments.
Maintain files per unit protocols.
Enter data into claims processing systems, document management systems, databases, and spreadsheets.
Assist with pharmacy projects, including distribution of education materials, letters & mailings, and reports.
Prior Authorizations (PA) and Formulary Exceptions
Verify member eligibility and applicable benefit for drug coverage.
Review member medication and eligibility history; load authorization in the claims adjudication platform.
Assist members and providers with PA, formulary exception, and coverage determination.
Facilitate resolution for PA and formulary exception requests; notify stakeholders of decisions.
Perform PA reviews with pharmacist oversight.
Appeals and Grievances
Explain pharmacy appeal and grievance provisions and processes to stakeholders.
Collect data for appeals & reconsiderations; prepare appeals for review by Pharmacists & Medical Directors.
Complete and notify stakeholders of appeal outcomes.
Assist coordination of pharmacy benefit appeals and grievances with relevant teams.
Project Coordination
Assist with pharmacy benefit projects under pharmacist and/or operations supervisor guidance, including process improvements, cost-saving initiatives, benefit implementation/changes, and member/provider/pharmacy outreach.
Required Experience and Education
Minimum 2 years in a pharmacy team (retail, long‑term care, or hospital) or 2 years in a health insurance plan.
Minimum 1 year experience with managed care and/or pharmacy benefit management.
Preferred Qualifications (Priority)
Pharmacy Technician Certification (CPhT).
Experience with daily calls with providers and members.
Willingness to work a rotation schedule 3–4 times a year.
Knowledge, Skills, and Abilities
Advanced knowledge of medical and pharmaceutical terminology.
Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
Proficient with Microsoft Office and CareOregon/PBM software.
Excellent verbal and written communication; active listening.
Ability to learn and navigate new systems, policies, and procedures.
Strong problem‑solving, organization, and prioritization skills.
Teamwork with diverse stakeholders and independent work under minimal supervision.
Stress management and professional conduct in all interactions.
Working Conditions Work Environment: Office/Indoor; occasional travel; flexible work schedule including work from home.
Physical Demands: General office equipment; may require repetitive finger and wrist movement; ability to speak and hear clearly for extended periods.
Benefits and Compensation Competitive salary with bonus opportunity, comprehensive medical, dental, vision, life, and AD&D insurance; retirement plan with employer contributions; PTO, paid state sick leave, and additional perks. Benefits-eligible employees qualify beginning on the first of the month after their start date.
Equal Opportunity Employer CareOregon is an equal opportunity employer. We select the best candidate for the job based on qualifications, regardless of race, color, religion, sexual orientation, gender identity, national origin, or disability. Reasonable accommodations will be provided for qualified individuals with disabilities.
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