The Offer
• Opportunity within a company with a solid track record of performance
• A role that offers a breadth of learning opportunities
• Fantastic work culture
Ideal Candidate
Key Responsibilities:
• Review pertinent patient information and check appropriateness using clinical criteria.
• Make approval recommendations on all services that meet clinical review criteria. Refer all cases not meeting clinical criteria to pharmacist clinical reviewer.
• Practice and maintain the principles of utilization management by adhering to company policies and procedures.
• Uphold clinical integrity of pharmaceutical solutions by participating in ongoing training programs to ensure quality performance in compliance with applicable standards and regulations.
• Assist with the documentation and implementation of both written and verbal communications to physicians/prescribers and assist in the maintenance of the edits and data elements that support the edits.
• Be available for consultation on… pharmacy-related questions to resolve claims submission related to medication edits.
• Contact physicians/prescribers to obtain pertinent clinical history/information.
• Provide optimum customer service through professional/accurate communication while maintaining NCQA and health plan’s required timeframes.
• Regularly review and monitor information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data.
• Support Intake call volume and order entry if necessary.
• Determine eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enter approvals or denials in the system.
• Electronically document both written and verbal communications with physicians, their staff, cardholders, and pharmacies.
• Escalate medical exception requests to nurse, pharmacist, or physician on the utilization review clinical team when further review is necessary.
The Profile
• You have at least 2 years experience within a Customer Service role, ideally within the Hospital / Health Care / Healthtech, Pharmaceutical industry.
• You possess excellent interpersonal as well as written and verbal communication skills.
• You pay strong attention to detail and deliver work that is of a high standard
• You are a self-starter and demonstrate a high level of resilience
• You are a strong team player who can manage multiple stakeholders
• You have a University Degree – Certified Pharmacy Technician (Required).
• Licensed in Florida, Illinois, Indiana, or Wisconsin (Required).
• Fluent in English (US) (Required) to effectively liaise with stakeholders in the region.
• Living in the USA due to HIPAA compliance.
• 4 to 6 years of supply chain or customer support service experience (Preferred)
The Employer
Our client is a Centralized and Standardized Native Customer Support Services Worldwide Sole provider of all Major Languages and Dialects in the World International Marketplace of Premium Contact Center Projects for Remote Talents
