Remote USA

Job Summary

While maintaining the integrity of the sensitive information of our membership, a Pharmacy Customer Service Representative is to provide efficient and accurate responses to external customers (physicians/office staff, pharmacy providers, members, and agents) and internal team members regarding health plan benefits including accessing services, resolving complex problems, pharmacy claim rejections and overrides, group/member eligibility problems, and other non-routine questions. Educates customers on drug formulary guidelines, including drug formulary alternatives and prior authorization criteria. Consistently create an exceptional experience with each contact, via inbound and outbound calls, face-to-face interactions, online chat, fax, email, etc.

Essential Functions

Demonstrates high competency in analyzing, evaluating, and responding to complex pharmacy benefit inquiries from members, providers, employer groups, colleagues, agents, Elite agents, and different customer types across multiple Priority Health products within departmental guidelines. Professional and pleasant interactions are ongoing expectations
Utilizes clinical knowledge from pharmacy experience and/or education to be able to effectively discuss covered alternatives to find less expensive options on the formulary to treat diagnosis
Collaborating with internal and external resources, promptly provides customers with information and education concerning the drug formulary and prior authorization (coverage determination) requests and ensuring they are completed in a timely manner in accordance with NCQA & CMS requirements
Promptly recognizes customer concerns, grievances, and/or appeal rights resolving or escalating to the proper channels to achieve positive outcomes
Adheres to established procedure and quality guidelines in support of Priority Health service promise, key drivers, performance indicators, as well as Corporate values and codes of excellence. Identifies potential trends or issues that impact health plan members and works with coworkers and leadership resources to suggest process improvements
Maintains CPhT certification through continuing education via CE Credits to ensure accuracy, consistency, and knowledge of current pharmacy practices/drug changes.
*If currently certified/licensed
Effectively documents all service interactions with customers within appropriate systems according to guidelines
Develops and maintains behaviors of productivity, availability to customers, and adherence to work schedule.

Qualifications

Required

High School Diploma or equivalent
1 year of relevant experience customer-facing service on phone or face to face; customer service, high volume call center, insurance environment relevant to benefits, and/or managed health care
1 year of relevant experience Pharmacy technician experience, pharmacy billing/claim adjudication

Preferred

CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board Upon Hire Or
LIC-Pharmacy Technician - STATE_MI State of Michigan Upon Hire

About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids (Remote)

Department Name

Pharmacy Contact Center - PH Managed Benefits

Employment Type

Full time

Shift

Variable (United States of America)

Weekly Scheduled Hours

Hours of Work

8 a.m. to 8 p.m.

Days Worked

Variable Monday to Friday

Weekend Frequency

Variable weekends

CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

Corewell Health

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Pharmacy Customer Service Representative