Customer Service - Pharmacy Technical Support Specialist

JOB SUMMARY :

Focus on prospective, concurrent and retrospective review of medical services provided to members enrolled in CommunityCare. Take into consideration benefits members are entitled to, access to services, site of care, the quality of services rendered and the cost of care. Provides medically appropriate services that are a covered benefit to members with attention focused on quality and efficiency. Provides Quality of care services in a cost-effective manner to preserve member benefits and minimize unnecessary healthcare costs. Processes are conducted, and decisions are made in compliance with State and Federal utilization management regulations. This position will report to the director of pharmacy.

KEY RESPONSIBILITIES :

• Process incoming authorization requests regarding services for members from providers
• Verifies eligibility, claim status, coinsurance and all other information related to a member and their benefits or a provider and their contract.
• Collaborate with healthcare providers for clinical information needed for determination requests.
• Accurately document case interactions with healthcare providers and members.
• Resolve claims adjudication issues related to medical benefits.
• Demonstrate ability and learning agility to adapt to organizational changes including business processes, systems and technology.
• Taking part in training and other learning opportunities to expand knowledge of company and position.
• Perform other duties as assigned.

QUALIFICATIONS :

EDUCATION / EXPERIENCE :

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin