Job Description
Position Summary: The Pharmacy Care Representative performs duties to support the efforts of the pharmacy operations and solutions department in the development, coordination, and maintenance of the health plan’s pharmacy benefits and services. The Pharmacy Care Representative is primarily responsible for supporting day-to-day administrative and operational activities for Apex’s clinical and quality management programs. In this role, the Pharmacy Care Representative will interact with multiple external and internal stakeholders including, but not limited to, Pharmacists, Providers, Care Managers, Pharmaceutical Industry Representatives, and Members. This position is also responsible to support the operations and oversight process of the client’s pharmacy programs and its delegated vendors such as the Pharmacy Benefit Manager (PBM) in accordance with all federal and state laws.
Essential Duties and Responsibilities: - Serve as an initial point of contact and facilitate timely and accurate responses to members, clients, team members, or other internal inquiries as needed.
- Handles and records outbound/inbound pharmacy calls from members, providers, and pharmacies to meet departmental, State regulations, NCQA guidelines, and CMS standards.
- Explains Point of Sale claims adjudication, state, NCQA, and CMS policy/guidelines, and any other necessary information to providers, members, and pharmacies.
- Effectively communicates plan benefit information, including but not limited to, formulary information, copay amounts, pharmacy location services and prior authorization outcomes.
- Collaborate with Pharmacy Operations and Solutions departmental pharmacists on Medication Therapy Management (MTM) program and conduct outreaches as needed.
- Support pharmacists with completion of comprehensive medication reviews or any additional programs through pre-work up to case preparation.
- Timely support of required activities to track and trend drug utilization patterns, audit for prior authorizations, analyze cost and determine trending data for departmental KPIs.
- Execute Pharmacy department’s clinical and financial programs with administrative tasks.
- Navigate systems, reporting, and resources to effectively answer questions and resolve issues.
- Assists with clerical services/tasks and other day-to-day operations as delegated.
- Supports ad-hoc projects and audit activities as needed.
- Supports and works collaboratively with the rest of the pharmacy team to ensure seamless communication and provide support for ongoing projects and initiatives.
- Other duties as assigned by leadership team.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
In addition to the qualifications below, the qualified candidate must have:
- Knowledge of general pharmacy operations.
- Advanced Microsoft office experience preferred (Excel, Word, PowerPoint, Visio).
- Prior experience working in a call center, specialty pharmacy, patient assistance program, or customer service role or experiences.
- Prior experience working in a health plan or a managed care environment.
- Working knowledge of MTM or PBM systems preferred.
- Strong verbal and written skills with excellent phone etiquette.
- Have analytical skills with attention to detail.
- Ability to exercise independent judgment and commitment to high quality work.
- Ability to manage deliverables in a fast-paced environment.
- Ability to meet strict deadlines and deliver project results within a specific timeframe.
- Must be a team player.
- Must be able to work on-site as required by the company or leadership team.
Competencies: To perform the job successfully, an individual should demonstrate the following:
Adaptability - Adapts to changes in the work environment. Manages competing demands. Accepts criticism and feedback. Changes approach or method to best fit the situation.
Communication - Expresses ideas and thoughts verbally. Expresses ideas and thoughts in written form. Exhibits good listening and comprehension. Keeps others adequately informed. Selects and uses appropriate communication methods.
Dependability - Responds to requests for service and assistance. Follows instructions, responds to management direction. Takes responsibility for own actions. Commits to doing the best job possible. Keeps commitments. Meets attendance and punctuality guidelines.
Quality - Demonstrates accuracy and thoroughness. Displays commitment to excellence. Looks for ways to improve and promote quality. Applies feedback to improve performance. Monitors own work to ensure quality.
Quantity - Meets productivity standards. Completes work in timely manner. Strives to increase productivity. Works quickly. Achieves established goals.
Teamwork - Balances team and individual responsibilities. Exhibits objectivity and openness to others' views. Gives and welcomes feedback. Contributes to building a positive team spirit. Puts success of team above own interests.
Education/Experience: - High School Diploma or Equivalent required.
Preferred :
- One (1) to Three (3) years of experience as a pharmacy tech in a retail or community pharmacy setting, health plan, HMO, PBM and/or healthcare industry settings.
- Prior work experience in a managed care environment or healthcare education. Medicare and/or Medicaid experience preferred.
Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
ABOUT APEX HEALTH SOLUTIONS Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.
Job Tags
Full time, Work experience placement,