Job Summary
While maintaining the integrity of the sensitive information of our membership, a Pharmacy Customer Service Representative provides efficient and accurate responses to external customers (physicians/office staff, pharmacy providers, members, and agents) and internal team members regarding health plan benefits including accessing services, resolving complex problems, pharmacy claim rejections and overrides, group/member eligibility problems, and other non-routine questions. Educates customers on drug formulary guidelines, including drug formulary alternatives and prior authorization criteria. Consistently creates an exceptional experience with each contact, via inbound and outbound calls, face-to-face interactions, online chat, fax, email, etc.
Essential Functions
Demonstrates high competency in analyzing, evaluating, and responding to complex pharmacy benefit inquiries from members, providers, employer groups, colleagues, agents, Elite agents, and different customer types across multiple Priority Health products within departmental guidelines. Professional and pleasant interactions are ongoing expectations.
Utilizes clinical knowledge from pharmacy experience and/or education to discuss covered alternatives to find less expensive options on the formulary to treat diagnosis.
Collaborates with internal and external resources to promptly provide customers with information and education concerning the drug formulary and prior authorization (coverage determination) requests and ensures they are completed in a timely manner in accordance with NCQA & CMS requirements.
Promptly recognizes customer concerns, grievances, and/or appeal rights, resolving or escalating to the proper channels to achieve positive outcomes.
Adheres to established procedures and quality guidelines in support of Priority Health service promises, key drivers, performance indicators, as well as Corporate values and codes of excellence. Identifies potential trends or issues that impact health plan members and works with coworkers and leadership resources to suggest process improvements.
Maintains CPhT certification through continuing education via CE credits to ensure accuracy, consistency, and knowledge of current pharmacy practices/drug changes.
If currently certified/licensed.
Effectively documents all service interactions with customers within appropriate systems according to guidelines.
Develops and maintains behaviors of productivity, availability to customers, and adherence to work schedule.
Qualifications Required
High School Diploma or equivalent
1 year of relevant experience in customer-facing service on the phone or in person; customer service, high-volume call center, insurance environment relevant to benefits, and/or managed health care
1 year of relevant experience in Pharmacy technician experience, pharmacy billing/claim adjudication
Preferred
Associate's degree
CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board Upon Hire Or
LIC-Pharmacy Technician - STATE_MI State of Michigan Upon Hire
About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name Pharmacy Contact Center - PH Managed Benefits
Employment Type Full time
Shift Variable (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8 a.m. to 8 p.m.
Days Worked Variable Monday to Friday
Weekend Frequency Variable weekends
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with vaccine requirements where applicable. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, perform essential functions, or enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. We advocate for equity as we care for our patients, our communities, and each other. We invite those who share in our commitment to join our team.
#J-18808-Ljbffr
While maintaining the integrity of the sensitive information of our membership, a Pharmacy Customer Service Representative provides efficient and accurate responses to external customers (physicians/office staff, pharmacy providers, members, and agents) and internal team members regarding health plan benefits including accessing services, resolving complex problems, pharmacy claim rejections and overrides, group/member eligibility problems, and other non-routine questions. Educates customers on drug formulary guidelines, including drug formulary alternatives and prior authorization criteria. Consistently creates an exceptional experience with each contact, via inbound and outbound calls, face-to-face interactions, online chat, fax, email, etc.
Essential Functions
Demonstrates high competency in analyzing, evaluating, and responding to complex pharmacy benefit inquiries from members, providers, employer groups, colleagues, agents, Elite agents, and different customer types across multiple Priority Health products within departmental guidelines. Professional and pleasant interactions are ongoing expectations.
Utilizes clinical knowledge from pharmacy experience and/or education to discuss covered alternatives to find less expensive options on the formulary to treat diagnosis.
Collaborates with internal and external resources to promptly provide customers with information and education concerning the drug formulary and prior authorization (coverage determination) requests and ensures they are completed in a timely manner in accordance with NCQA & CMS requirements.
Promptly recognizes customer concerns, grievances, and/or appeal rights, resolving or escalating to the proper channels to achieve positive outcomes.
Adheres to established procedures and quality guidelines in support of Priority Health service promises, key drivers, performance indicators, as well as Corporate values and codes of excellence. Identifies potential trends or issues that impact health plan members and works with coworkers and leadership resources to suggest process improvements.
Maintains CPhT certification through continuing education via CE credits to ensure accuracy, consistency, and knowledge of current pharmacy practices/drug changes.
If currently certified/licensed.
Effectively documents all service interactions with customers within appropriate systems according to guidelines.
Develops and maintains behaviors of productivity, availability to customers, and adherence to work schedule.
Qualifications Required
High School Diploma or equivalent
1 year of relevant experience in customer-facing service on the phone or in person; customer service, high-volume call center, insurance environment relevant to benefits, and/or managed health care
1 year of relevant experience in Pharmacy technician experience, pharmacy billing/claim adjudication
Preferred
Associate's degree
CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board Upon Hire Or
LIC-Pharmacy Technician - STATE_MI State of Michigan Upon Hire
About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name Pharmacy Contact Center - PH Managed Benefits
Employment Type Full time
Shift Variable (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8 a.m. to 8 p.m.
Days Worked Variable Monday to Friday
Weekend Frequency Variable weekends
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with vaccine requirements where applicable. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, perform essential functions, or enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. We advocate for equity as we care for our patients, our communities, and each other. We invite those who share in our commitment to join our team.
#J-18808-Ljbffr