Pharmacy Resolution Specialist at Centene

**Who this is for** This role is for detail-oriented individuals with strong customer service skills who are passionate about helping health plan members resolv

Work type: remote

Location: Remote-MI

Salary: $16 – $27/hr

Type: Full-time

Summary

**Who this is for** This role is for detail-oriented individuals with strong customer service skills who are passionate about helping health plan members resolve pharmacy-related inquiries. If you thrive in a call center environment and enjoy problem-solving, this is a great opportunity. **Key highlights** As a Pharmacy Resolution Specialist, you will be the primary point of contact for members, pharmacies, and providers, resolving inquiries about benefits, prior authorizations, and claims. This fully remote position allows you to work from anywhere while making a significant impact on member satisfaction. **You might be a good fit if you...** - Have a High School Diploma or GED and at least 1 year of call center or customer service experience. - Are adept at researching issues and providing clear, accurate resolutions within established timelines. - Possess strong knowledge of pharmacy benefits and the ability to interpret complex guidelines. - Are comfortable making outbound and receiving inbound calls, meticulously documenting interactions.

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 for this role must be available to work 9:30AM-6:00PM EST. 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

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.

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