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Pharmacy Benefit Specialist II
CareOregon. Provide customer service to CareOregon members, providers, pharmacies, and staff regarding pharmacy benefits and prescription needs .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates advanced knowledge of medical and pharmaceutical terminology, along with proficiency in pharmacy benefit management and managed care concepts. Capable of providing exceptional customer service while maintaining confidentiality under HIPAA and effectively managing pharmacy claims and appeals.
Highest-signal resume keywords
Pharmacy Benefit ManagementManaged Care ExperienceMedical and Pharmaceutical TerminologyClaims ProcessingCustomer Service
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AdjudicationData EntryFormulary ExceptionsPrior Authorization ReviewsEligibility VerificationProcess ImprovementDocumentation ManagementPharmacy Appeals ProcessingSpreadsheet ManagementConfidentiality Compliance
Soft Skills
Advanced Communication SkillsOrganizational SkillsIndependent WorkListening SkillsPrioritization Skills
Tools & Technologies
Microsoft Office ProductsCareOregon SoftwarePBM Software
Industry Keywords
HIPAA ComplianceOregon Health PlanMedicarePharmacy BenefitsHealth Insurance
About the role
Key responsibilities & impact- Provide customer service to CareOregon members, providers, pharmacies, and staff regarding pharmacy benefits and prescription needs
- Process pharmacy claims and resolve or triage claims adjudication issues
- Educate members, providers, pharmacies, and staff about formularies and pharmacy benefit policies
- Document customer service activities and maintain confidentiality under HIPAA
- Sort incoming faxes and maintain files
- Perform data entry in claims processing, document management, database, and spreadsheet systems
- Support pharmacy projects through education materials, letters, mailings, and reports
- Verify plan eligibility and benefits for drug coverage
- Review medication and eligibility history and load authorizations in claims adjudication platforms
- Assist with prior authorizations, formulary exceptions, and coverage determinations
- Perform prior authorization reviews with pharmacist oversight and notify stakeholders of decisions
- Intake, prepare, process, and communicate outcomes for pharmacy appeals and grievances
- Assist pharmacists, medical directors, and coordinators with appeals and grievances
- Support pharmacy benefit projects involving process improvements, cost savings, benefit changes, and outreach
Requirements
What you’ll need- Minimum 2 years work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 2 years’ experience in a health insurance plan
- Minimum 1 year experience with managed care and/or pharmacy benefit management
- Advanced knowledge of medical and pharmaceutical terminology
- Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts
- Proficient with Microsoft Office Products and general computer literacy
- Ability to learn and effectively navigate CareOregon and PBM software programs
- Ability to follow and provide input into policies and procedures
- Advanced listening, verbal, and written communication skills
- Ability to organize, plan, and prioritize daily workflow and projects
- Ability to work independently with minimal supervision
- Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
- Ability to hear and speak clearly for at least 3-6 hours/day
Benefits
Comp & perks- Bonus - SIP Target, 5% Annual
- Medical, dental, vision, life, AD&D, and disability insurance
- Health savings account
- Flexible spending account(s)
- Lifestyle spending account
- Employee assistance program
- Wellness program
- Discounts
- Supplemental benefits including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings
- Retirement plan with employer contributions
- PTO
- Paid State Sick Time
- Paid holidays
- Volunteer time
- Jury duty leave
- Bereavement leave
- 401(k) contributions
- Remote work from home