Senior Pharmacy Benefits Specialist - St. Luke's Health Plan - job 1 of 2
Overview
Overview:
The Senior Pharmacy Benefits Specialist assists our members in identifying and navigating complex pharmacy benefits management (PBM) and third-party issues such as prior authorization, step therapy, reviewing denied claims, and processing overrides. Works with an interdisciplinary team of pharmacy staff, patient financial advocates, the pharmacy authorization team, clinic staff, and providers. Issues insurance overrides and processes prior authorizations.
What to expect:
- Establish and maintain collaborative working relationships with pharmacies, members, and providers.
- Will serve as first-line contact for escalated pharmacy, member, and provider concerns.
- Will assist in the training and onboarding of all new pharmacy benefits team members.
- Review the supporting clinical documentation provided by a patient's prescriber and validate that information against the drug and therapeutic indication for that situation.
- Apply in-depth knowledge of high-cost specialty medications, the applicable pharmaceutical regulations, and requirements to align member and Health Plan cost containment strategies.
- Navigate federal laws that may impact patients from participating in manufacturer copay card programs.
- Accurately calculate costs and savings while processing specialty medications.
- Provide customer service and explain complex insurance topics to patients and providers.
- Apply working knowledge of insurance plan design and terminology (deductible, max out of pocket, co-insurance, etc.)
- Interpret medical terminology and accurately process prior authorization requests for medications under the pharmacy benefits.
- Facilitate resolutions to issues involving claims adjudication, member concerns, and provider communications.
- Addresses complex questions from third-party payers and medical staff regarding medication issues and reimbursement.
- Serve as subject matter expert (SME) on resolving claim rejections, copay assistance programs, and escalated prior authorization appeals.
- Will assist in preparing for and leading team member meetings.
- Serves as a role model and mentor to other Pharmacy Benefits Specialists.
- Performs other duties and responsibilities as assigned.
Requirements:
- Education: High School diploma or equivalent
- Experience: 3 years of experience
- Licenses/Certifications: Valid Idaho Pharmacy Technician License
What’s in it for you
At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Virgin Pulse Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.
St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.
*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.
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St. Luke’s is driven by our mission to improve the health of people in the communities we serve, which is grounded in our focus on population and community health. Our strategy leads us to achieving our vision as we build upon and enhance our repu...
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