Resolveoutpatient pharmacy benefit coverage prescription claimprocessingassistance, communicates drug formulary guidelines including drug formulary alternatives, prior authorization criteria and group/member eligibility problems.
Responsibilities
Performs initial review ofmember-initiated drug prior authorization requests and approve based upon P&T approved medication policies or pend for clinical review.
Complies with established processes to ensures prior authorizations requests are completed within regulatory turnaround times.
Researches and resolves physician inquiries related to prior authorization requests.
Supports BSC Member Services with resolution of pharmacy benefit issues that cannot be handled by front line CSRs.
Using motivational interviewing, educate members about medication use issues such as medication adherence,90-day supply promotion, etc.
Supports implementation of procedures and procedures for the outpatient prescription drug prior authorization program.
Provides formulary alternatives, member drug profiles, communicates prior authorization criteria, and other pertinent pharmacy benefit related information to authorized individuals upon request.
Quickly assesses thecaller'sissue and provides first level support for problem resolution.
Performs other duties and assists with projects as assigned by supervisor.
Refers to policies and practices for guidance on non-standard problems.
Seeks guidance on non-routine assignments from peers orhigher-levelteam members.
Education and Experience
HS Diploma and1 year of Pharmacy related experience and training
Proficient in knowledge of Microsoft office (Word, PowerPoint, Visio & Excel)
State Board or Nationallyas Certified PharmacyTech required
Additional Information
About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail.
EEO Footer: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
