Pharmacy Representative ID-15558

May 19, 2025

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Position Summary:

The Pharmacy Operations Analyst 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 Analyst supports inquiries from other business areas via phone and email.

This role is eligible for our eWorker, Mobile, or Resident personas

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Your Day to Day:

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 accurately 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 on line 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

Please note, due to the nature of this role, the team is on a rotational schedule that does require team members to work every 5th or 6th Saturday.

***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.

We're Looking for:

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.

What You Bring:

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

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