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Estimated Hiring Range:

Bonus Target:

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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Essential Responsibilities

Customer Service and Claims Processing

• Communicate in a professional and respectful manner.
• Maintain confidentiality within HIPAA regulations and function on “need to know” principles.
• Respond to drug coverage inquires in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff.
• Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies.
• Document all customer service activities according to organization requirements.
• Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit.
• Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance.

Data Entry and Clerical Support

• Sort incoming faxes and distribute according to assignments.
• Maintain files according to unit protocols.
• Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned.
• Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports.

Prior Authorizations (PA) and Formulary Exceptions

• Verify member’s plan eligibility and applicable benefit for drug coverage.
• Review member’s medication and eligibility history, load authorization in claim adjudication platform(s).
• Assist members and providers with the PA, formulary exception and coverage determination process.
• Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions.
• Perform prior authorization reviews with pharmacist oversight.

Appeals and Grievances

• Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff.
• Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors.
• Complete pharmacy appeals and notify members and providers of outcome.
• Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances.

Project Coordination

• Under the supervision of a pharmacist and/or the operations supervisor, assist with pharmacy benefit projects including, but not limited to process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach.

Experience and/or Education

Required

• Minimum 2 years work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 2 years’ experience in a health insurance plan
• Minimum 1 year experience with managed care and/or pharmacy benefit management

Preferred

• Pharmacy Technician Certification (CPhT)
• Pharmacy Technician experience
• Pharmacy related outbound calls experience

Knowledge, Skills and Abilities Required

Knowledge

• Advanced knowledge of medical and pharmaceutical terminology
• Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts

Skills and Abilities

• Proficient with Microsoft Office Products and general computer literacy
• Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities
• Ability to follow and provide input into policies and procedures in performing job responsibilities
• Advanced listening, verbal, and written communication skills
• Ability to exercise professionalism
• Proficient ability to network and utilize internal and external resources
• Ability to focus on and comprehend information
• Ability to learn new skills and abilities
• Ability to assess a situation and seek or determine appropriate resolution
• Ability to accept managerial direction and feedback
• Ability to tolerate and manage stress
• Results and service oriented
• Ability to be flexible and adaptable
• Ability to organize, plan, and prioritize daily workflow and projects within time constraints
• Ability to work in an environment with diverse individuals and groups
• Ability to work independently with minimal supervision
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s):         ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security                       ☐ Outdoor Exposure

Member/Patient Facing:     ☒ No                        ☐ Telephonic       ☐ In Person

Hazards:  May include, but not limited to, physical and ergonomic hazards.

Equipment:  General office equipment

Travel:  May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

Work Location: Work from home

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.  Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.