It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: Reporting to the Manager of Pharmacy Operations, the Pharmacy Operations Specialist is primarily responsible for supporting the pharmacy utilization management programs, processing prior authorization requests, and providing pharmacy-related customer service to internal and external parties. In addition, the Operations Specialist will support the day-to-day operations of the pharmacy program as needed. Our Investment in You: · Full-time remote work · Competitive salaries Key Functions/Responsibilities: · Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements · Properly apply clinical policy criteria to the review of prior authorization requests · Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email · Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements · Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications · Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits · Provide pharmacy-related customer service to both internal and external parties · Process pharmacy authorizations utilizing PBM real time online claims adjudication software · Support new clinical program implementation · Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Pharmacy Policy interpretation, and plan design interpretation · Other responsibilities as needed Qualifications: Education: · Minimum of a High School diploma or equivalent required · Associate or Bachelor’s degree preferred Experience: · Two or more years of experience in a professional or pharmacy setting · Previous experience in a managed care environment preferred · Prior customer service experience preferred Competencies, Skills, and Attributes: · Excellent Customer Service skills · Prior experience assisting members and/or providers with telephone inquiries · Strong organizational, problem solving, communication, and interpersonal skills · Excellent written and oral communication skills required · Must have strong data entry and attention to detail in building cases · Must be able to multitask and be results oriented

Compensation

Range: $20.19 - $28.37 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. Note: This range is based on Boston-area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees