Welcome Back

Google icon Sign in with Google
OR
I agree to abide by Pharmadaily Terms of Service and its Privacy Policy

Create Account

Google icon Sign up with Google
OR
By signing up, you agree to our Terms of Service and Privacy Policy
Instagram
youtube
Facebook

Pharmacy Operations Specialist

Wellsense Health Plan
WellSense Health plan
3-5 years
Not Disclosed
10 Dec. 5, 2024
Job Description
Job Type: Full Time Remote Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences/High School diploma or equivalent Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

Pharmacy Operations Specialist

Location: Remote (United States)

About WellSense Health Plan:
WellSense Health Plan is a nonprofit health insurance provider serving over 740,000 members across Massachusetts and New Hampshire through Medicare, Medicaid, and Individual & Family plans. With over 25 years of experience, we are committed to delivering high-quality healthcare solutions tailored to the diverse needs of our members.


Job Summary:

The Pharmacy Operations Specialist, reporting to the Manager of Pharmacy Operations, will be responsible for supporting pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service. The role also involves assisting in the day-to-day operations of the pharmacy program.


Key Responsibilities

  • Prior Authorization Requests:

    • Process and review prior authorization requests via fax, phone, or electronic systems in compliance with regulatory and accreditation standards.
    • Apply clinical policy criteria to authorization reviews.
  • Data Management & Customer Support:

    • Review and interpret member eligibility, claims history, and Pharmacy Program information using PBM claims software.
    • Provide pharmacy-related support to internal and external clients via telephone and email.
    • Communicate determinations to members and providers via calls, faxes, and letters.
  • Issue Resolution & Analysis:

    • Address issues related to formulary administration and benefits.
    • Support the implementation of new clinical programs.
    • Serve as a liaison for Member Services and internal teams regarding pharmacy benefit, policy, and plan design interpretation.
  • Multitasking & Administrative Support:

    • Handle multiple tasks efficiently while ensuring accuracy in data entry and case building.
    • Assist with other pharmacy-related responsibilities as needed.

Qualifications

Education:

  • High School diploma or equivalent (required).
  • Associate or Bachelor’s degree (preferred).

Experience Required:

  • Minimum of 2 years of experience in a professional or pharmacy setting.
  • Experience in a managed care environment (preferred).
  • Prior customer service experience (preferred).

Competencies, Skills, and Attributes

  • Customer Service:

    • Strong skills in assisting members and providers with inquiries and issues.
    • Ability to communicate clearly and professionally.
  • Organizational & Analytical Skills:

    • Ability to multitask and manage time effectively.
    • Strong attention to detail and data entry accuracy.
  • Communication Skills:

    • Excellent oral and written communication abilities.
    • Ability to interpret and explain complex information to internal and external clients.

Why Join WellSense?

  • Remote Flexibility: Full-time remote work available.
  • Competitive Benefits: Comprehensive salary and benefits package.
  • Inclusive Culture: WellSense is committed to diversity and inclusion in staffing and member services.

Equal Opportunity Employer:
WellSense is an equal opportunity employer, committed to diversity and inclusion. Qualified applicants are considered without regard to race, gender, disability, or veteran status.

Apply Today:
Join a team dedicated to improving healthcare outcomes. Visit WellSense Careers to apply.