Website:
urs.org
Job details:
About The Company
PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.
For most jobs, remote work is available for 9 out of every 10 workdays.
Job Description
This position is available at three levels. Candidates will be considered for the level that best matches their qualifications and experience.
Pharmacy Clinical Specialist I- Min: $19.73/hr. Max: $24.67/hr.
Pharmacy Clinical Specialist II- Min: $21.52/hr. Max: $26.90/hr.
Pharmacy Clinical Specialist III- Min: $23.44/hr. Max: $29.30/hr.
Position Summary
This position supports PEHP’s efforts to mitigate the rising cost of health care and provide excellent customer service. This position performs a variety of support duties including clinical services technical support, customer service support, and education through inbound and outbound communications. This position also collaborates with PEHP nurses, pharmacists, and doctors; provides customer service to PEHP members and network physicians; solves problems with pre-authorizations or claims and assists the Clinical Management department in pre-authorization evaluation and the disputed/appealed pre-authorization process. The successful candidate will have excellent communication skills, a basic understanding of medical terminology, understand medical claims payments, the ability to learn and apply new information, and is willing to go the extra mile to provide excellent customer service. The incumbent must always demonstrate good judgment, high integrity, and personal values consistent with the values of URS.
Essential Job Functions And Duties
- Performs first level review for cases being entered into computer operating systems to ensure eligibility, plan limits, and benefits are up to date and complete.
- Responds to issues, questions, and concerns from PEHP members, providers, and internal customers via incoming and outgoing phone calls, written correspondence, fax, email, etc. Responds to questions regarding policy description and interpretations, payment processes, and eligibility for covered services. Assists callers in the proper procedures related to claims corrections and appeals.
- Educates members, providers, and pharmacies through outbound phone calls on company policies and plan benefits.
- Communicates pre-authorization and disputed prior authorization approvals/denials with physicians, members, PEHP Member and Provider Services department, PEHP Clinical Management department, and the PEHP Member Claims department through mailings, inbound/outbound phone calls, and the PEHP Message Center.
- Logs information into appropriate computer software programs. Maintains documentation to ensure that information is current, accurate, and easily understood by claims adjusters, customer service, and other departments as needed.
- Provides information on co-pay assistance programs offered through pharmaceutical manufacturers.
- Identifies requests for out-of-network services and directs care to in-network providers. Educates on out-of-network costs and potential for balance billing.
- Evaluates and determines coverage on prior authorization requests for pharmacy, medical benefits, and durable medical equipment (DME) in a timely manner.
- Prepares and collects clinical information for disputes and appeals. Forwards to the appropriate Clinical Management staff.
- Works closely with providers, vendors, and members to obtain all necessary information for pre-authorization and ensures completion in a timely manner.
- Manages a high volume of incoming calls and written correspondence.
- Maintains regular and reliable attendance.
- Maintains strict confidentiality (HIPAA compliant).
- Performs other related duties as assigned.
Required Experience
Pharmacy Clinical Specialist I
High School diploma and two (2) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.) , or an equivalent combination of education and experience.
Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred.
Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred.
Pharmacy Clinical Specialist II
High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.) , or an equivalent combination of education and experience .
Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred.
Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred.
Pharmacy Clinical Specialist III
High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.) , competency in medical terminology and anatomy is required, or an equivalent combination of education and experience. In addition, one (1) year of experience in the clinical services role.
Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), Certified Professional Coder (CPC) and/or licensure as a registered pharmacy technician (CPhT) is preferred.
Specific experience in claims processing, pharmacy software applications, and electronic billing procedures is preferred.
Knowledge, Skills, And Abilities
This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:
Required technical skills include the working knowledge and ability of:
- Various office management systems related to alpha and numeric record keeping.
- Healthcare Information Systems.
- Pharmacy software programs.
- Electronic billing procedures.
- Personal computer operations.
- Microsoft Office Suite.
- 10-key.
Required Working Knowledge Of
- Medical, dental, pharmaceutical, and Medicare Supplement claims adjudication policies, procedures, and processes.
- Intricacies related to medical, dental, pharmaceutical, and mental health claims.
- Claims review processes and procedures.
- Healthcare coding.
- Enrollment processes.
- Basic medical terminology.
- Pharmacy adjudication policies.
- Intricacies related to drug usage, dosage, definitions, and codes.
Must Possess Excellent Communication Skills
- Telephone etiquette.
- Public relations skills.
- Communicate effectively verbally and in writing.
- Establish and maintain effective working relationships with professionals, executives, department heads, coworkers, and the public.
Must Have The Ability To
- Multi-task by handling a variety of duties in a timely and efficient manner.
- Document information accurately and succinctly.
- Apply intermediate mathematics related to the metric system to calculate drug dosages as related to pharmacy/medical claims.
- Follow written and verbal instructions.
- Follow a well-organized work routine.
- Deal effectively with stress caused by workload and time deadlines and handling difficult or irate phone calls.
- Work well in a team environment as well as independently.
- Prioritize work.
- Perform within deadlines.
- Follow through with assignments.
The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.
Work Environment
Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing, and seeing. Common eye, hand, finger dexterity required to perform essential functions.
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