Pharmacy Specialist I

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects. This position must ensure performance is in compliance with organizational or departmental goals and in compliance with regulatory agencies. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs and based on clinical criteria.

Responsibilities:

• Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues.

• Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design.

• Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination.

• Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied

• Process complaints, appeals, grievances, executive inquiries and compliance related issues.

• Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary.

• Provide recommendations to increase efficiency, accuracy and productivity in the department.

• Process ad hoc request for information or reports from stakeholders.

• Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows.

• Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program.

• Provide support to various clinical programs within the pharmacy department.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required

• Requires minimum of two (2) years experience as a Pharmacy technician

• Prefers minimum of two (2) years experience in third party prescription program claim adjudication.

• Requires prior customer service/service quality initiative experience.

Additional licensing, certifications, registrations:

• Requires National Pharmacy Technician Certification (PTCB or ExCPT)

• In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required.

Knowledge:

• Requires knowledge of popular brand and generic drug names.

• Requires knowledge of third party prescription program claim adjudication.

• Requires working knowledge of managed care principles.

• Requires knowledge of common medical terminology.

• Requires understanding of National Drug Code (NDC).

• Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation.

Skills and Abilities:

• Requires the ability to utilize a personal computer and ap