Blue Cross Blue Shield of Massachusetts Pharmacy Operations Representative in Quincy, Massachusetts
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The Pharmacy Operations Analyst is responsible for primary contact for our providers to obtain authorization for retail pharmacy, home infusion and medical utilization management requests. These requests are received via fax, phone and web. In addition, the Pharmacy Operations Analyst supports inquiries from other business areas via phone and email.
Receive, process, and archive provider’s retail fax and phone authorization requests accurately using multiple computer systems against our Medical Policy Criteria
Review and interpret member’s eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email
Analyze and interpret high level medical data and accurately data entry information according to NCQA guidelines
Receive, process, and archive Home Infusion Therapy and Utilization Management Medical requests accurately using MCPS/Express Path and other systems via fax or telephone
Communicate determinations to providers via incoming and outgoing telephone calls.
Process pharmacy authorizations utilizing PBM real time on line claims adjudication software.
Support new clinical program implementation
Serve as a liaison to Member Services and other internal clients for real-time support on pharmacy benefit interpretation, Medical Policy interpretation, and plan design interpretation.
Support Medicare Part D and understanding of CMS guidelines
Other responsibilities as needed
Qualification (Knowledge, skills, and abilities):
Excellent Customer Service skills
Prior experience assisting members and/or providers with telephone inquiries
Strong organizational, problem solving, communication, and interpersonal skills
Excellent written and oral communication skills required.
Must have strong data entry and attention to detail in building cases
Must be able to multitask and be results oriented.
Minimum of a High School diploma required. Associate or Bachelor’s degree preferred.
Proficiency in MCPS and Foundation 14 preferred
Experience in a Windows environment preferred
Previous experience in a managed care environment preferred
Previous pharmacy experience preferred.
LocationQuincyTime TypeFull time
Voted as one of the Most Admired Health Care Companies in 2014 by Boston Business Journal, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.
Our Commitment to You
We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.
Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.
Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.