Position Title: Pharmacy Customer Service Assistant II 

Grade: F

Department: Pharmacy Plan Customer Service

 

QUALIFICATIONS:

 

REQUIRED TESTING:

 

Alpha-numeric data entry test (6,000 keystrokes)

JEPS Math

 

REQUIRED:

 

High School diploma or GED

Three years recent Pharmacy Technician experience in a pharmacy that includes familiarity with pharmacy benefits, pharmacy claims, and working with difficult customers in person and via telephone; or three years Prior Authorization and pharmacy benefit experience at a pharmacy benefit company or health plan outside of HealthPartners/GHI.

Six-months computer experience including pharmacy systems

Broad knowledge of drugs and drug categories

Broad knowledge of pharmacy benefits

Demonstrated independent analytic problem solving skills

Excellent written and oral communication skills

Demonstrated ability to convey information to others in a clear, concise, and courteous manner by phone, direct contact, and in writing

Ability to make decision based on established protocols. Ability to deal effectively with varying workloads, stress levels and tight deadlines

Ability to work independently and establish work priorities in an environment with frequent interruptions

Ability to maintain productive working relationships with team members and other internal and external customers with exceptional customer service skills

Ability to work independently and make appropriate decision following corporate guidelines with the ability to research and fully document internal practices or problems that contribute to customer dissatisfaction in order to reduce future complaints and errors.

Exceptional organizational skills

 

PREFERRED:

 

Completion of Pharmacy Tech program

Certified Pharmacy Technician (CPhT) Certification

Knowledge of HealthPartners and HealthPartners Pharmacy Administration department

 

 

PHYSICAL REQUIREMENTS:

This position requires the use of close, visual perception and normal manual dexterity. Incumbent must be able to sit for prolonged periods of time. Must be able to speak, read and write English fluently.

 

 

 

POSITION PURPOSE:

Service Excellence is to be centered on patient care and patient relationships and is the responsibility of all employees. Teamwork is the norm and all employees will be held accountable to work as effective team members.

 

The Pharmacy Customer Service Assistant II reviews requests for medical policy or prescription drugs that require a coverage determination. This is primarily a pharmacy customer service position that serves as a resource to providers, members, member service staff, pharmacies, and department staff with regard to pharmacy benefits, pharmacy claims, formulary, and pharmacy policy and procedures. Physician and member requests are processed independently by reviewing requests based on pre-determined clinical criteria. This position also reviews and determines appropriate reimbursements/processing of all claims requested from members and providers. This position applies all accountabilities below to all of HealthPartners products including Fully Insured, Self-Insured, Medicare, and Medicaid.

 

 

ACCOUNTABILITIES:

Key contact for expedited, urgent, and complex benefit and pharmacy issues including coverage determination, benefit design, and claims. Interpret unique and complex benefits.

Organize, retrieve, and share member information under tight timelines in accordance with state and federal policies including but not limited to National Council Quality Assurance, ERISA, and CMS (Centers for Medicare and Medicaid Services)

Process requests using HIPAA security measures.

Assist in internal and external audits.

Identify and interpret Explanation of Benefits received from members and other carriers.

Provide excellent customer service to, providers, members, member services staff, internal and external staff, and pharmacies regarding pharmacy benefits and claims, formulary, and pharmacy policy and procedures for all HealthPartners products (i.e. Fully Insured, Self Insured, Medicare, and Medicaid). Focus on ownership and first call resolution. Evaluate and redirect calls to appropriate areas or departments.

Correspond with Medicare members, Member Services, Sales, brokers, Membership Accounting, clinics, pharmacies, and other departments regarding coverage determinations and pharmacy benefits. Independently process a high volume of coverage determination requests within established guidelines and based on pre-determined clinical criteria.

Research and triage pharmacy claims submitted by members and providers.

Handle all call center duties with knowledge of department functions, processes and procedures professionally, courteously, and competently. Provide guidance to other staff regarding daily priorities and service levels.

Manage department’s shared Outlook mailbox including, but not limited to, direct member reimbursement (DMR) claims, vaccine claims, Case Management restricted members, and “Ask a Pharmacist” folder.

Build rapport with coworkers, internal customers, pharmacies, vendors and members by demonstrating a strong customer service orientation and a continuous positive image of HealthPartners.

Advise on group and member pharmacy benefits. Research and report inconsistencies pertaining to pharmacy benefit, formulary management logic, and pharmacy adjudication. Independently resolve member’s pharmacy issue based on patient care and unique circumstances.

Organize and accurately log all information on several databases for reporting purposes.

Adhere to department policies and procedures regarding electronic storage of member records.

Manually load member/group enrollment information if needed.

Meet all established production and quality standards.

Assist in training new staff regarding pharmacy benefits, coverage determination, and departmental policy and procedures.

Perform all duties utilizing excellent customer service skills.

Perform other duties as required.

 

 

 

126310_Pharmacy_Cust_Serv_Asst_II.doc Page 3 of 3