Description

Job Description

Operations Specialist: Healthcare
3-month contract, extension possible
Location: Remote (EST hours likely)

$20-22/hr

Must Haves:

• HS diploma or equivalent education
• Two or more years of experience in a professional or pharmacy setting

Preferred:

• College degree
• Previous experience in a managed care environment preferred
• Prior customer service experience preferred

Job Summary/Description:

Responsibilities:

• Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements.
• Properly apply clinical policy criteria to the review of prior authorization requests
• Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email
• Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements
• Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications
• Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
• Provide pharmacy-related customer service to both internal and external parties.
• Process pharmacy authorizations utilizing PBM real time online claims adjudication software.
• Support new clinical program implementation
• Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation.
• Other responsibilities as needed

Qualifications/Skills:

• Minimum of a High School diploma or equivalent required. Associate or Bachelor’s degree preferred
• Two or more years of experience in a professional or pharmacy setting
• Previous experience in a managed care environment preferred
• Prior customer service experience preferred
• Excellent Customer Service skills
• Prior experience assisting members and/or providers with telephone inquiries
• Strong organizational, problem solving, communication, and interpersonal skills
• Excellent written and oral communication skills required.
• Must have strong data entry and attention to detail in building cases
• Must be able to multitask and be results oriented
• Looking for remote jobs near your area? At Yulys, thousands of employers are looking for exceptional talent like yours. Find perfect job now.