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    Pharmacy Operations Specialist

    Wellsense Health Plan
    3-5 years
    Not Disclosed
    Remote, USA
    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.

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