Customer Service - Pharmacy Technical Support Specialist 176-1030 at CommunityCare

Tulsa, Oklahoma, United States -

Full Time

Start Date

Immediate

Expiry Date

20 Mar, 26

Salary

0.0

Posted On

20 Dec, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Customer Service, Pharmacy, Managed Care, Health Insurance, Documentation, Claims Adjudication, Collaboration, Time Management, Attention to Detail, Microsoft Office, Judgment, Learning Agility, Infusion Therapies, Quality of Care, Cost-Effectiveness, Eligibility Verification

Industry

Insurance

Description

JOB SUMMARY: Focus on prospective, concurrent and retrospective review of medical services provided to members enrolled in CommunityCare. Take into consideration benefits members are entitled to, access to services, site of care, the quality of services rendered and the cost of care. Provides medically appropriate services that are a covered benefit to members with attention focused on quality and efficiency. Provides Quality of care services in a cost-effective manner to preserve member benefits and minimize unnecessary healthcare costs. Processes are conducted, and decisions are made in compliance with State and Federal utilization management regulations. This position will report to the director of pharmacy. KEY RESPONSIBILITIES: Process incoming authorization requests regarding services for members from providers Verifies eligibility, claim status, coinsurance and all other information related to a member and their benefits or a provider and their contract. Collaborate with healthcare providers for clinical information needed for determination requests. Accurately document case interactions with healthcare providers and members. Resolve claims adjudication issues related to medical benefits. Demonstrate ability and learning agility to adapt to organizational changes including business processes, systems and technology. Taking part in training and other learning opportunities to expand knowledge of company and position. Perform other duties as assigned. QUALIFICATIONS: Experience in managed care, PBM, or health plan setting preferred Ability to read, comprehend, and explain health insurance benefits in a clear, concise, and professional manner. Dedicated to working in a collaborative, multi-team environment to provide the best care for our members. Ability to work independently and apply good judgment. Proficient in Microsoft Office applications. Highly organized and attentive to detail. Strong time management skills. Knowledge of infusion therapies is preferred. Successful completion of Health Care Sanctions background check. EDUCATION/EXPERIENCE: High school diploma or equivalent. Two years’ experience in managed care pharmacy benefits, pharmacy tech or related discipline. Basic understanding of Health Plan Industry. One year customer service experience required. Previous customer service experience in a Medicare Advantage plan preferred. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

Responsibilities

The specialist processes incoming authorization requests and verifies member eligibility and claim status. They collaborate with healthcare providers for clinical information and document case interactions accurately.