Pharmacy Resolution Specialist

📋 Description

• • As a Pharmacy Resolution Specialist at Centene Corporation, you will play a pivotal role within our Medical Management/Health Services team, directly impacting the lives of our 28 million members. This remote position, based in Florida, offers a unique opportunity to leverage your customer service and pharmacy knowledge to resolve complex issues for our diverse membership.
• • Your primary responsibility will be to serve as the first point of contact for members, provider/physician offices, and pharmacies, addressing inquiries related to pharmacy benefits and coverage. This involves handling a high volume of inbound calls with professionalism and efficiency, ensuring a positive member experience.
• • A key aspect of this role is managing prior authorization requests. You will guide members and providers through the process, offering clear explanations of benefit options and facilitating the submission of necessary documentation for clinical review.
• • You will be empowered to thoroughly research and investigate member and provider issues, utilizing comprehensive reference materials and internal systems to identify root causes and implement effective solutions. This requires a keen analytical mind and a commitment to accuracy.
• • Resolution of inquiries and complaints is paramount. You will meticulously log, track, and resolve all assigned cases, adhering strictly to turnaround time requirements and quality standards. Your efforts will directly contribute to enhancing member satisfaction and strengthening Centene's relationships with its stakeholders.
• • Maintaining an expert-level understanding of all pharmacy benefits, formularies, and relevant CMS regulations is crucial. This knowledge base will enable you to accurately interpret and communicate complex information to a variety of audiences, ensuring compliance and member understanding.
• • You will be responsible for interpreting both pharmacy and medical benefits, providing clear and concise explanations to members and providers. This requires a nuanced understanding of healthcare coverage and the ability to translate technical jargon into accessible language.
• • Beyond inbound calls, you will also conduct outbound calls to members and provider offices to gather additional information, provide updates on medication determinations, and ensure timely resolution of outstanding claims.
• • Active participation in the initiation and status updates for prior authorization, coverage determination, and appeal/redetermination processes is a core function. You will be a key liaison, ensuring all parties are informed and that processes move forward efficiently.
• • A strong emphasis is placed on outstanding attention to detail. In this role, accuracy in data entry, information gathering, and communication is non-negotiable, as it directly impacts member care and regulatory compliance.
• • You will be encouraged to identify systemic issues and potential root causes that may affect a larger group of members or providers. Communicating these findings to relevant teams is vital for driving enterprise-wide improvements and ensuring first-call resolution whenever possible.
• • This role may also involve assisting with special projects, contributing to process improvements, and collaborating with various departments to enhance operational efficiency and member services.
• • You will be expected to perform other duties as assigned, demonstrating flexibility and a willingness to support the team's objectives.
• • Strict adherence to all company policies, standards, and regulatory guidelines is mandatory, ensuring the integrity and compliance of all operations.
• • This position requires you to work a consistent schedule of 8:30 AM to 5:00 PM EST, Monday through Friday, providing a predictable work environment.
• • You will be joining a dynamic and supportive team within a leading national healthcare organization, contributing to a mission of improving the health of its members.
• • The role offers a significant opportunity for professional growth and development within the healthcare industry, with potential for advancement based on performance and dedication.
• • You will be part of an organization that values diversity and inclusion, fostering a welcoming and equitable work environment for all employees.