Pharmacy Specialist I

Horizon Connect @ Wall BCBSNJ

. Receive verbal and written prior authorization requests from pharmacists, physicians, and/or members .

Posted 11/6/2026full-timeRemote • United StatesJuniorMid-Level💰 $44,600 - $59,745 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Pharmacy Services, including prior authorization processes, claim adjudication, and regulatory compliance. Proficient in customer service, clinical information capture, and collaboration with healthcare professionals to optimize patient care.

Highest-signal resume keywords

Pharmacy Technician CertificationPrior Authorization ProcessingThird Party Prescription Program Claim AdjudicationKnowledge of Managed Care PrinciplesEffective Verbal and Written Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prior Authorization ProcessingClaim AdjudicationKnowledge of Medical TerminologyUnderstanding of National Drug CodeKnowledge of Pharmacy Regulations

Soft Skills

Effective CommunicationTime ManagementProblem SolvingTeam CollaborationCustomer Service Focus

Tools & Technologies

Personal ComputerPharmacy Software

Certifications & Qualifications

National Pharmacy Technician CertificationPTCBExCPT

Industry Keywords

Pharmacy Benefit ManagementManaged CareClinical Therapeutic InterchangeFormulary ComplianceFraud Detection

About the role

Key responsibilities & impact

Receive verbal and written prior authorization requests from pharmacists, physicians, and/or members
Support and assist in coordinating Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence, and special projects
Process prior authorization requests received via fax or prior authorization help line by evaluating medical necessity and appropriateness for specific drugs based on clinical criteria
Handle telephonic interactions with members, physician office staff, pharmacies, and internal stakeholders regarding Pharmacy eligibility, coverage determination, and claim issues
Engage physicians and pharmacists in clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and maintain consistency with current plan design
Capture accurate and comprehensive clinical information for prior authorization requests to support clinical review and medical necessity determinations
Satisfy departmental customer service quality metrics and DMAHS/DOBI regulatory turnaround times
Process complaints, appeals, grievances, executive inquiries, and compliance-related issues
Identify potential fraud, waste, and abuse and make necessary internal referrals
Provide recommendations to increase department efficiency, accuracy, and productivity
Process ad hoc information or report requests from stakeholders
Complete independent and group learning to understand pharmacy services procedures and workflows
Assist with day-to-day pharmacy department functions and the Medication Therapy Management program
Support various clinical programs within the pharmacy department

Requirements

What you’ll need

High School Diploma/GED required
Requires minimum of two (2) years experience as a Pharmacy technician
Prefers minimum of two (2) years experience in third party prescription program claim adjudication
Requires prior customer service/service quality initiative experience
Requires National Pharmacy Technician Certification (PTCB or ExCPT)
In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required
Requires knowledge of popular brand and generic drug names
Requires knowledge of third party prescription program claim adjudication
Requires working knowledge of managed care principles
Requires knowledge of common medical terminology
Requires understanding of National Drug Code (NDC)
Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation
Requires the ability to utilize a personal computer and applicable software
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team
Demonstrated ability to deliver highly technical information to less technical individuals
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development
Proven time management skills; ability to manage multiple priorities, deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency
Demonstrated ability to work in a production focused environment
Proven ability to exercise sound judgment and strong problem solving skills
Proven ability to ask probing questions and obtain thorough and relevant information

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement