Job Description
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
*Qualified candidates must be available to work 9:30AM-6:00PM EST Monday-Friday*
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Position Purpose: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
Offers options including submission of a prior authorization request
Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards
Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position
Responsible for knowing and interpreting pharmacy and medical benefits
Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls
Responsible for ensuring outstanding attention to detail
Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution
Assists with special projects as assigned
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: High School Diploma / GED and 1 year of Job Specific call center/customer service. Pharmacy experience strongly preferred.
Pay Range: $15.87 - $27.25 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, ****** orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
*Qualified candidates must be available to work 9:30AM-6:00PM EST Monday-Friday*
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Position Purpose: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.
Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
Offers options including submission of a prior authorization request
Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards
Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards
Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position
Responsible for knowing and interpreting pharmacy and medical benefits
Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls
Responsible for ensuring outstanding attention to detail
Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution
Assists with special projects as assigned
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: High School Diploma / GED and 1 year of Job Specific call center/customer service. Pharmacy experience strongly preferred.
Pay Range: $15.87 - $27.25 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, ****** orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
💡 Quick Summary
Seeking a career-building opportunity? The Pharmacy Resolution Specialist position is now open for candidates interested in the Work from home Jobs sector. This role in Baker offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Work from home Jobs is a plus.