Pharmacy Resolution Specialist

Centene Corporation; California (MO); On-site; USD 21,862 - 37,539; Full time

Benefits offered by this job

Health insurance

401K

Tuition reimbursement

Paid time off

Flexible work schedules

Job summary

A leading health services organization is seeking a Pharmacy Resolution Specialist to handle inquiries from members and providers. The role requires a High School Diploma and at least a year of customer service experience. Responsibilities include investigating claims and providing solutions while maintaining compliance with corporate guidelines. The position offers competitive pay ranging from $15.87 to $27.25 per hour along with a comprehensive benefits package including health insurance and 401K options.

Qualifications

• Minimum 1 year of job-specific call center or customer service experience.
• Must be authorized to work in the U.S. without visa sponsorship.
• Must maintain expert knowledge on pharmacy benefits.

Responsibilities

• Respond to calls from members and provider offices.
• Log, track, resolve, and respond to inquiries and complaints.
• Assist with special projects as assigned.

Skills

Customer service skills

Problem-solving

Attention to detail

Knowledge of pharmacy benefits

Education

High School Diploma / GED

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 9:30 AM–6:00 PM 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

Education / Experience

High School Diploma / GED and 1 year of Job Specific call center/customer service. 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.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.