Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary :

This position is responsible for receiving verbal and written request for prior authorization from pharmacists, physicians and / or patients and is responsible for supporting and assisting in the coordination of Pharmacy Services activities including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects.

Must maintain performance in compliance with organizational or department goals and in compliance with regulatory agencies.

Serves as a backup for department supervisor as needed.

Process prior authorizations received via prior authorization help line, by evaluating the medical necessity / appropriateness for specific drugs and based on medical criteria.

Conduct intervention with physician and pharmacy office staff to facilitate formulary compliance and generic dispensing.

• Directly interact with members physician office staff, pharmacies and internal stake holders for eligibility, coverage determination claims issues.
• Provide recommendations to increase efficiency, accuracy and productivity in the department.
• Process appeals complaints executive inquiries and compliance related issues.
• Research, recommend, monitor, develop and implement procedures; systemic or other revisions to increase efficiency, accuracy and productivity in the department and provide pharmaceutical information i.

e. drug pricing, to support market business units and provider service areas.

• Participate in client member and employee training to ensure practical understanding of pharmacy services programs and operations.
• Monitor day-to-day workflow metrics such as phone and fax request volumes and formulate strategies to better administer.
• Coach and train new employees to the department as needed and act as back up to the Pharmacy Benefit Analyst or immediate supervisor.
• Provide assistance in resolving the Physician / Member requests in a timely manner.

Core Individual Contributor Competencies :

Personal and professional attributes that are critical to successful performance for Individual Contributors :

Customer Focus

Accountable

Learn

Communicate

Education / Experience :

• Prefers a Bachelor's degree from an accredited college or university in Health Care Management, Business or Pharmaceutical Administration.
• Requires minimum of two (2) years experience in third party prescription program claim adjudication.
• Requires minimum of two (2) years experience as a Pharmacy Utilization Management Specialist.
• Requires prior customer service / service quality initiative experience.

Additional licensing, certifications, registrations :

Pharmacy Certification

Knowledge :

• Requires knowledge of popular brand and generic drug names.
• Requires knowledge of third party prescription program claim adjudication.
• Requires working knowledge of managed care principles.
• Requires knowledge of common medical terminology.
• Requires understanding of National Drug Code (NDC).
• Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation.

Skills and Abilities :

• Requires the ability to utilize a personal computer and applicable software.
• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.
• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities or tasks , deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.

Demonstrated ability to work in a production focused environment.

• Proven ability to exercise sound judgment and strong problem solving skills.
• Proven ability to ask probing questions and obtain thorough and relevant information.

Salary Range : $48,600 - $65,100

$48,600 - $65,100

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to : education, experience, licensure, certifications, geographic location, and internal equity.

This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Horizon also provides a comprehensive compensation and benefits package which includes :

Comprehensive health benefits (Medical / Dental / Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Last updated : 2024-06-11