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. Professional and pleasant interactions are ongoing expectations

• 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.

• 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

• Relocation assistance (OPTIONAL)

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 Required

• 2 years of relevant experience Pharmacy technician experience, pharmacy billing/claim adjudication Required

Preferred

• Associates degree

• CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board Upon Hire preferred Or

• LIC-Pharmacy Technician - STATE_MI State of Michigan Upon Hire preferred Or

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.

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