Pharmacy Customer Service Representative

Pharmacy Customer Service Representative

While maintaining the integrity of the sensitive information of our membership, a Pharmacy Customer Service Representative is to provide 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 create 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.
• Utilizes clinical knowledge from pharmacy experience and/or education to be able to effectively discuss covered alternatives to find less expensive options on the formulary to treat diagnosis.
• Collaborating with internal and external resources, promptly provides customers with information and education concerning the drug formulary and prior authorization (coverage determination) requests and ensuring 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 procedure and quality guidelines in support of Priority Health service promise, 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 customer-facing service on phone or face to face; customer service, high volume call center, insurance environment relevant to benefits, and/or managed health care.
• Preferred: Associate's Degree, CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board, LIC-Pharmacy Technician - STATE_MI State of Michigan.

Primary Location: SITE - Priority Health - 1231 E Beltline - 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: Variable 8 a.m. to 8 p.m. Days Worked: Monday to Friday Weekend Frequency: Variable weekends