Ready to help us transform healthcare? Bring your true colors to blue. 

Position Summary:

The Pharmacy Operations Representative is responsible for primary contact for our providers to obtain authorization for retail pharmacy, home infusion and medical utilization management requests. These requests are received via fax, phone and web. In addition, the Pharmacy Operations Representative supports inquiries from other business areas via phone and email.

***This position has been identified as essential to the operations of the company in the event of a building closure due to weather, emergency, or disaster. Holding an essential position, you may be expected to bring a company issued laptop home and work from home or other remote location in the event of a building closure, emergency, or disaster.

This position is also eligible for the following personas: Resident, Mobile, and eWorker.

Key Responsibilities:

• Receive, process, and archive provider’s retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria.
• 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.
• Analyze and interpret high level medical data and accurate data entry information according to NCQA guidelines.
• Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MHK and other systems via fax or telephone.
• Communicate determinations to providers via incoming and outgoing telephone calls.
• 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, Medical Policy interpretation, and plan design interpretation.
• Support Medicare Part D and understanding of CMS guidelines.
• Other responsibilities as needed.

Qualification (Knowledge, Skills, and Abilities):

• 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.

Education/Relevant Experience:

•  Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
•  Proficiency in MHK and PBM System preferred.
•  Experience in a Windows environment preferred.
•  Previous experience in a managed care environment preferred.
•  Previous pharmacy experience preferred.

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Time Type

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.  We may ultimately pay more or less than the posted range, and the range may be modified in the future.  An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note:  No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can  prevent  amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.