Pharmacy Resolution Specialist
7 days ago
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
* Remote based position anywhere in the United States, must be available to work Monday - Friday; 10:30 a.m. 7:00 p.m. EST.
Position Purpose: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
- Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
- Offers options including submission of a prior authorization request
- Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
- Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards
- Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position
- Responsible for knowing and interpreting pharmacy and medical benefits
- Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
- Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls
- Responsible for ensuring outstanding attention to detail
- Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution
- Assists with special projects as assigned
- Performs other duties as assigned
- Complies with all policies and standards
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
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