Representative, Pharmacy

JOB DESCRIPTION Job Summary Provides customer service support for inbound/outbound pharmacy calls from members, providers, and pharmacies. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties • Handles and records inbound/outbound pharmacy calls from members, providers and pharmacies in accordance with departmental policies, state regulations, National Committee of Quality Assurance (NCQA) guidelines, and Centers for Medicare and Medicaid Services (CMS) standards. • Provides coordination and processing of pharmacy prior authorization requests and/or appeals. • Explains point-of-sale claims adjudication, state, NCQA and CMS policies/guidelines, and any other necessary information to providers, members and pharmacies. • Assists with clerical tasks and other day-to-day pharmacy call center operations as delegated. • Effectively communicates plan benefit infor...