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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in pharmacy claims adjudication, benefit design, and medication management while effectively communicating with members, providers, and pharmacies. Proficient in utilizing AI-enabled tools for inquiry resolution and documentation, ensuring compliance and quality assurance.
Highest-signal resume keywords
National Pharmacy Technician CertificationPharmacy Claims AdjudicationBenefit Design KnowledgePatient Outreach SupportMultitasking and Prioritization
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Pharmacy Claims AdjudicationBenefit DesignMedication Cost AnalysisPrior Authorization CriteriaClinical Program EnrollmentDocumentation in Internal SystemsInquiry ResolutionAI-Enabled Tools UsageDetail OrientationAnalytical Skills
Soft Skills
AdaptabilityCommunicationTeam CollaborationProblem SolvingRespectful Interaction
Certifications & Qualifications
National Pharmacy Technician Certification
Industry Keywords
Health PlanRetail PharmacyTPAPBMClaims ProcessingMedication-Adherence Follow-UpQuality AssuranceComplianceDiverse Team EnvironmentCustomer Service
About the role
Key responsibilities & impact- Serve as the primary point of contact for members, providers, and pharmacies across phone, chat, email, and written correspondence
- Resolve inquiries related to mail order, benefit design, formulary coverage, medication cost, prior authorization criteria, and claims adjudication
- Support network pharmacies in processing prescription claims and review claims for accuracy
- Support clinical pharmacists with patient and provider outreach, appointment scheduling, clinical program enrollment, and medication-adherence follow-up
- Document interactions and resolutions in internal systems for continuity of care, quality assurance, compliance, and reporting
- Own issues from initial contact through final resolution, coordinating with internal teams as needed
- Use AI-enabled tools and internal knowledge systems to resolve inquiries and document interactions
- Foster a cooperative, respectful, and diverse team environment and complete assigned projects
Requirements
What you’ll need- Active/Current National Pharmacy Technician Certification (PTCB, NHA)
- 1 to 3 years as a pharmacy technician in a health plan, retail pharmacy setting, TPA, or PBM contact center role
- Working knowledge of pharmacy claims adjudication, benefit design, and PBM terminology
- Associate's or bachelor's degree preferred, or equivalent relevant work experience
- Detail oriented, adaptable, and analytical
- Ability to identify and resolve root causes
- Ability to support phone, chat, and email queues while multitasking and prioritizing
- Ability to support multiple lines of business and shifting priorities
Benefits
Comp & perks- Equal Opportunity Employer
- Inclusive culture where differences are celebrated
- AI-enabled tools and internal knowledge systems provided for work
