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Role Description

This position supports PEHP’s efforts to mitigate the rising cost of health care and provide excellent customer service. This position performs a variety of support duties including:

• Clinical services technical support
• Customer service support
• Education through inbound and outbound communications

The successful candidate will have excellent communication skills, a basic understanding of medical terminology, understand medical claims payments, the ability to learn and apply new information, and is willing to go the extra mile to provide excellent customer service. The incumbent must always demonstrate good judgment, high integrity, and personal values consistent with the values of URS.

Qualifications

• High School diploma and two (2) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), or an equivalent combination of education and experience for Pharmacy Clinical Specialist I
• High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), or an equivalent combination of education and experience for Pharmacy Clinical Specialist II
• High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), competency in medical terminology and anatomy is required, or an equivalent combination of education and experience for Pharmacy Clinical Specialist III
• Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred
• Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred

Requirements

• Performs first level review for cases being entered into computer operating systems to ensure eligibility, plan limits, and benefits are up to date and complete
• Responds to issues, questions, and concerns from PEHP members, providers, and internal customers via incoming and outgoing phone calls, written correspondence, fax, email, etc.
• Educates members, providers, and pharmacies through outbound phone calls on company policies and plan benefits
• Communicates pre-authorization and disputed prior authorization approvals/denials with physicians, members, and various departments
• Logs information into appropriate computer software programs and maintains documentation
• Provides information on co-pay assistance programs offered through pharmaceutical manufacturers
• Identifies requests for out-of-network services and directs care to in-network providers
• Evaluates and determines coverage on prior authorization requests for pharmacy, medical benefits, and durable medical equipment (DME)
• Prepares and collects clinical information for disputes and appeals
• Works closely with providers, vendors, and members to obtain all necessary information for pre-authorization
• Manages a high volume of incoming calls and written correspondence
• Maintains regular and reliable attendance
• Maintains strict confidentiality (HIPAA compliant)
• Performs other related duties as assigned

Benefits

• Competitive salary with generous benefits
• Personal development in a positive team environment
• Excellent work-life balance
• Remote work available for 9 out of every 10 workdays