Pharmacy Benefits Specialist I

Network Health; Menasha (WI); Hybrid; USD 42,000 - 56,000; Full time

Job summary

Network Health is seeking a Pharmacy Benefits Specialist I to support operational, planning, implementation and reporting for the Pharmaceutical Benefits area. You will build report queries, maintain financial reports, and resolve claim processing and benefit issues, acting as a resource on pharmacy benefits.

The role is based in Wisconsin with a hybrid work arrangement and standard 40-hour weeks. A Pharmacy Technician certification is preferred, with one year of related experience required.

Qualifications

• High School Diploma or equivalency required.
• One year of experience in a Pharmacy Tech position or one year of experience working with pharmacy benefits required.
• Certified Pharmacy Technician preferred.
• One (1) year of experience working with pharmacy benefits may substitute for certification.

Responsibilities

• Manage large mailings including letter preparation and mail merge.
• Create and maintain Prescription Benefit Summary of Member Responsibility Tables.
• Produce reports for Prior Authorization, physician utilization, and KPI board metrics.
• Research and resolution of benefit issues; review denials and manage related tasks.
• Assist with benefit testing and respond to formulary status questions.

Education

High School Diploma

Certified Pharmacy Technician

Job description

The Pharmacy Benefits Specialist I provide basic operational, planning, implementation and reporting support for the Pharmaceutical Benefits area of Network Health Plan. In addition to providing administrative support for the pharmaceutical area of Network Health, this role will build report queries and maintain operational and financial reports, research and resolve claim processing and benefit issues, act as a technical resource for internal users regarding pharmacy benefits, and maintain pharmacy formularies in written and web formats.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required) in combination with at our office in in our hybrid workplace model.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Job Responsibilities

• Manage large mailings including letter preparation, mail merge, and distribution
• Create and maintain Prescription Benefit Summary of Member Responsibility Tables
• Provide a variety of reports for internal and external stakeholders including Prior Authorization, physician utilization, Controlled Substance Reporting, Annual Quality Improvement Program Evaluation, call log and drug reports related to Key Performance Indicator Board, and working with Sales to run standard reports from Pharmacy Benefits Manager (PBM)
• Complete files reviews for denials
• Maintain J-Code Tier Levels billing tables for claims
• Answer formulary status questions for Commercial and Medicare Sales, and Customer Service
• Assist Care Management/Disease Management with benefit questions, Prior Authorization requirements, and grievances
• Pull data for reporting pharmacy trends.
• Manage the PBM Satisfaction Survey process
• Research and resolution of benefit issues
• Benefit testing
• Other duties and responsibilities as assigned

Job Requirements

• High School Diploma or equivalency required
• One year of experience in a Pharmacy Tech position or one year of experience working with pharmacy benefits required
• Certified Pharmacy Technician preferred
• One (1) year of experience working with pharmacy benefits may substitute for certification

Network Health is an Equal Opportunity Employer