Pharmacy Resolution Specialist

Company: Centene Corporation
Location: Jefferson City
Posted on: May 18, 2024

Job Description:

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Job Description
Position Purpose: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.

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  Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests. Offers options including submission of a prior authorization request. Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
  
  
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  Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards
  
  
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  Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position. Responsible for knowing and interpreting pharmacy and medical benefits
  
  
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  Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
  
  
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  Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls. Responsible for ensuring outstanding attention to detail
  
  
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  Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution
  
  
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  Assists with special projects as assigned
  
  
  Education/Experience: High School Diploma / GED
  1 year of Job Specific call center/customer service
  Computer skills- Microsoft office, typing
  Ability to evaluate information from both oral and written sources, pharmaceutical references
  Ability to follow direction
  Pay Range: $15.29 - $26.20 per hour
  Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
  Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Keywords: Centene Corporation, Saint Peters , Pharmacy Resolution Specialist, Healthcare , Jefferson City, Missouri