Imagine RX Pharmacy Services Representative

Imagine360; United States; On-site; USD 38,000 - 54,000; Full time

Benefits offered by this job

Health plan options

Company paid life insurance

Parental Leave Policy

Paid time off 20 days to start

Tuition reimbursement

401k company contribution

Long-term Disability

Professional development opportunities

Diversity and inclusion initiatives

Job summary

Imagine360 seeks an Imagine RX Pharmacy Services Representative to be the first point of contact for members, providers, and pharmacies, delivering accurate, empathetic RX benefits support.

You will guide callers on Formulary coverage, medication costs, and order status, while handling eligibility inquiries and claims reviews. The role emphasizes HIPAA compliance and thorough documentation.

Qualifications

• High School Diploma or GED required.
• Active/Current National Pharmacy Technician Certification (PTCB or NHA) required.
• 1–3 years of pharmacy technician experience in health plan, retail, TPA or PBM contact center.
• Knowledge of pharmacy claims adjudication, benefit design and PBM terminology.
• Strong listening, rapport-building and compassionate customer service.

Responsibilities

• Serve as the primary point of contact for members, providers and pharmacies for RX claims processing information.
• Guide callers on prescription benefits, formulary coverage, medication cost and order status.
• Respond to benefit eligibility and prescription status inquiries and assist network pharmacies with claims processing.
• Assist with PA status checks and initiate PA by contacting providers.
• Answer questions related to rejections and resolutions.
• Document interactions and resolutions in internal systems, ensuring HIPAA compliance (PHI).
• Take ownership from initial contact to final resolution and escalate when needed.

Skills

Pharmacy technician experience

Customer service

HIPAA compliance

Communication skills

Education

High School Diploma or GED

PTCB or NHA Certification

Associate's or Bachelor's degree preferred

Tools

PBM terminology

Windows applications

Job description

Imagine360 is seeking an Imagine RX Pharmacy Services Representative to join the team! In this role, you'll serve as the first point of contact for members, providers, and pharmacies. This role delivers accurate, empathetic support on prescription benefits, refill requests, billing or order issues, formulary coverage, medication cost, prior authorization criteria, claims adjudication, and clinical program enrollment.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Serve as the primary point of contact for members, providers, and pharmacies, applying customer needs assessment and quality service standards to confer with customers and provide accurate, timely information related to RX claims processing.
• Guide and educate callers on prescription benefits, use of plan, mail order, formulary coverage, medication cost, and the status of orders, claims, or inquiries.
• Respond to inbound calls regarding benefit eligibility and prescription status inquiries, and assist network pharmacies in processing prescription claims, reviewing claims for accuracy against benefit guidelines and contract standards.
• Assist with general PA (Prior Authorization) status checks, initiate a PA by contacting the provider, and direct providers on how to start a PA.
• Answer common questions related to rejections and resolutions associated with requests.
• Ask appropriate questions and listen attentively, accurately documenting each interaction and resolution in internal systems to support continuity of care, quality assurance, compliance requirements, and operational reporting. Abide by all obligations under HIPAA related to Protected Health Information (PHI)
• Take ownership of member, provider, and pharmacy issues from initial contact through final resolution, following up timely to ensure appropriate changes were made and conferring with the Liviniti Support Team on inquiries out of your scope or that become escalated.
• Foster a team environment that values cooperation, respect, and diversity, and take on other duties and projects as assigned.

Required Experience/Education:

• High School Diploma or GED required
• Active/Current National Pharmacy Technician Certification required (PTCB or NHA)
• 1 to 3 years of experience as a pharmacy technician in a health plan, retail pharmacy, TPA, or PBM contact center setting; mail order and specialty pharmacy backgrounds are also a strong fit
• Working knowledge of pharmacy claims adjudication, benefit design, and PBM terminology
• Demonstrated ability to listen skillfully, gather relevant information, build rapport, and respond to customers in a compassionate, detail-oriented manner, with the ability to dig past a symptom to find and resolve the true root cause
• Familiarity with computer and Windows PC applications, including the ability to navigate and learn new and complex computer system applications, and comfortable multitasking and prioritizing

Preferred Experience/Education:

• Associate's or Bachelor's degree preferred, or equivalent relevant work experience

What can Imagine360 offer you?

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.