PBM Operations Specialist

$68,640 - $68,640/Yr

Meduvi - Boston, MA

Full-time - Entry Level

Boston, MA

Administrative and Support Services

About the position

The Pharmacy Operations Specialist is responsible for supporting pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service. This role involves ensuring compliance with regulatory and accreditation requirements while assisting in the day-to-day operations of the pharmacy program.

Responsibilities

• Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems.
• Properly apply clinical policy criteria to the review of prior authorization requests.
• Review and interpret member's eligibility, claim history, and Pharmacy Program information using PBM claims software.
• Communicate determinations to members and providers via telephone calls, fax notifications, and letter notifications.
• Provide pharmacy-related customer service to both internal and external parties.
• Process pharmacy authorizations utilizing PBM real-time online claims adjudication software.
• Support new clinical program implementation.
• Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation.

Requirements

• Minimum of a High School diploma or equivalent required.
• Two or more years of experience in a professional or pharmacy setting.
• Previous experience in a managed care environment preferred.
• Prior customer service experience preferred.

Nice-to-haves

• Associate or Bachelor's degree preferred.

Benefits

• 401(k)
• Comprehensive medical (HMO/PPO)
• Dental (PPO)
• Weekly payroll with direct deposit