Health Services Representative II - Pharmacy
PacificSource Health Plans - Bend, OR

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Overview:

Coordinate application of pharmacy services and benefits. Handle pharmacy-related inquiries and communicate benefit determination. Act as a liaison and information resource to internal and external pharmacy services customer. Provide pharmacy services Help-Desk. Provide pharmacy claims processing services. Conduct claims audits and prepare prior authorization statistics.

Responsibilities:

1. Act as principal contact regarding drug preauthorizations and system overrides. Help to resolve issues related to pharmacy services.

2. Provide customer service handling of pharmacy-related calls. Collect appropriate clinical and benefit information. Relate determination decisions.

3. Function as liaison with pharmacy benefit management company, pharmacies, physicians, and others in order to apply benefits, and assist with pharmacy benefits determinations .

4. Research new pharmaceuticals and indications to help determine clinical appropriateness, cost, coverage, and copayments.

5. Consult with Director of Pharmacy Services and other professional staff in determining coverage for pharmacy-related services and pharmaceuticals.

6. Prepare and process member-submitted pharmacy claims in the pharmacy benefit managers claims processing system.

7. Ensure all coverage determinations are processed in a timely and accurate manner, consistent with Medicare & Medicaid (if applicable) oversight and department policies.

8. Provide support and maintenance for department communication tools (ie. Sharepoint), if applicable.

9. Assist Pharmacy Director to ensure compliance with government programs (FWA, P&P development, CMS & DMAP policies, Report generation & submission, etc), if applicable.

10. Perform other duties as assigned.

Relationships: PacificSource employees and managers, agents, patients, physicians, network pharmacies, and vendors.

Qualifications:

Work Experience: Pharmacy Technician, Pharmacy Assistant, or equivalent experience. One year of customer service or health insurance experience desirable.

Language skills: Excellent verbal and business writing communications skills. Excellent public relations skills. Good understanding of Medical Terminology required.

Mathematical Skills: Ability to compile and organize statistical and numerical data.

Reasoning Ability: Requires ability to define and prioritize problems and manage workload without direct supervision.

Education, Certificates, Licenses, Registration: Minimum high school diploma and relevant work experience. Bachelors degree preferred. Certification as a pharmacy technician through the Pharmacy Technician Certification Board is desired.

Other Skills and Abilities: Medical terminology. Can distribute reports to pharmaceutical representatives, management, agents, and other internal/external customers. Excellent spreadsheet, word processing, and graphics packages skills for personal computer.

Environment:

Position requires work inside in a general office setting with ergonomically configured equipment.

Mental / Physical Requirement:

This position requires the ability to communicate clearly and distinctly in person and over a voice telephone, to operate a standard computer keyboard, and to read printed materials and computer screens.

Disclaimer

This job description indicates the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.

PacificSource is an equal opportunity and affirmative action employer.

PacificSource Health Plans - 18 months ago - save job - block
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About this company
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PacificSource Health Plans is anything but a typical health plan. We’re a growing, independent, not-for-profit organization with a...