Pharmacy Benefits Specialist - St. Luke's Health Plan
US-ID-Boise
careers
Req #: 98646
Type: Full-Time
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Overview: At St. Luke's Health Plan, we're on a mission to connect people with affordable, hassle-free health care. We are the only health plan in Idaho putting doctors and insurance on the same team to deliver a more efficient and quality health care experience with less stress. Join us in this bold ambitious journey. We'd love to hear from you! The Pharmacy Benefits Specialist assists our members in identifying and navigating pharmacy benefits management (PBM) and third-party issues such as prior authorization, step therapy, reviewing denied claims, and processing overrides. The ideal candidate works with an interdisciplinary team of pharmacy staff, patient financial advocates, the pharmacy authorization team, clinic staff, and providers. Issues insurance overrides and processes prior authorizations. If you have PBM, retail and/or strong pharmacy billing expereince and have a valid Idaho Pharmacy Tech license, this position may be for you. * Establish and maintain collaborative working relationships with pharmacies, members, and providers. * Review the supporting clinical documentation provided by a patient's prescriber and validate that information against the drug and therapeutic indication for that situation. * Apply knowledge of high-cost specialty medications, the applicable pharmaceutical regulations, and requirements to align member and Health Plan cost containment strategies. * Navigate federal laws that may impact patients from participating in manufacturer copay card programs. * Accurately calculate costs and savings while processing specialty medications. * Provide customer service and explain insurance topics to patients and providers. * Apply working knowledge of insurance plan design and terminology (deductible, max out of pocket, co-insurance, etc.) * Interpret medical terminology and accurately process prior authorization requests for medications under the pharmacy benefits. * Facilitate resolutions to issues involving claims adjudication, member concerns, and provider communications. * Addresses questions from third-party payers and medical staff regarding medication issues and reimbursement. * Performs other duties and responsibilities as assigned. Job Description Qualifications * Education: High School diploma or equivalent * Experience: 1 year of experience * Licenses/Certifications: Valid Idaho Pharmacy Technician License Preferred Qualifications * PTCB * PBM Experience * Strong Pharmacy Insurance Experience Responsibilities: The Pharmacy Benefits Specialist assists our members in identifying and navigating pharmacy benefits management (PBM) and third-party issues such as prior authorization, step therapy, reviewing denied claims, and processing overrides. Works with an interdisciplinary team of pharmacy staff, patient financial advocates, the pharmacy authorization team, clinic staff, and providers. Issues insurance overrides and processes prior authorizations. * Establish and maintain collaborative working relationships with pharmacies, members, and providers. * Review the supporting clinical documentation provided by a patient's prescriber and validate that information against the drug and therapeutic indication for that situation. * Apply knowledge of high-cost specialty medications, the applicable pharmaceutical regulations, and requirements to align member and Health Plan cost containment strategies. * Navigate federal laws that may impact patients from participating in manufacturer copay card programs. * Accurately calculate costs and savings while processing specialty medications. * Provide customer service and explain insurance topics to patients and providers. * Apply working knowledge of insurance plan design and terminology (deductible, max out of pocket, co-insurance, etc.) * Interpret medical terminology and accurately process prior authorization requests for medications under the pharmacy benefits. * Facilitate resolutions to issues involving claims adjudication, member concerns, and provider communications. * Addresses questions from third-party payers and medical staff regarding medication issues and reimbursement. * Performs other duties and responsibilities as assigned. Qualifications: * Education: High School diploma or equivalent * Experience: 1 year of experience * Licenses/Certifications: Valid Idaho Pharmacy Technician License
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