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Job Description

Job Summary

Must be able to start on 09.12.2022

Must live within the State of Michigan for Virtual work requirements.

On-site work may be requested if employee performance needs attention, internet issues or power outages that may occur.

6 Weeks of training (2-3 days on-site)

Training Hours 8:30 a.m. to 5 p.m. Monday to Friday

Attendance during training is required

Post Training Hours can vary between:

7:30 a.m. to 8 p.m.. Call Center hours of operation

Shift lengths can be either 8 or 10 hours

Must be available for Saturday, and late night shift rotations

Pay $17.69 to $18.69

* based on experience, education and department evaluation.

While maintaining the integrity of the sensitive information of our membership, a Pharmacy Customer Service Representative is to provide efficient and accurate responses to external customers (physicians/office staff, pharmacy providers, members, and agents) and internal team members regarding health plan benefits including accessing services, resolving complex problems, pharmacy claim rejections and overrides, group/member eligibility problems, and other non-routine questions. Educates customers on drug formulary guidelines, including drug formulary alternatives and prior authorization criteria. Consistently create an exceptional experience with each contact, via inbound and outbound calls, face-to-face interactions, online chat, fax, email, etc.

Essential Functions

• Demonstrates high competency in analyzing, evaluating, and responding to complex pharmacy benefit inquiries from members, providers, employer groups, colleagues, agents, Elite agents, and different customer types across multiple Priority Health products within departmental guidelines. Professional and pleasant interactions are ongoing expectations
• Utilizes clinical knowledge from pharmacy experience and/or education to be able to effectively discuss covered alternatives to find less expensive options on the formulary to treat diagnosis
• Collaborating with internal and external resources, promptly provides customers with information and education concerning the drug formulary and prior authorization (coverage determination) requests and ensuring they are completed in a timely manner in accordance with NCQA & CMS requirements
• Promptly recognizes customer concerns, grievances, and/or appeal rights resolving or escalating to the proper channels to achieve positive outcomes
• Adheres to established procedure and quality guidelines in support of Priority Health service promise, key drivers, performance indicators, as well as Corporate values and codes of excellence. Identifies potential trends or issues that impact health plan members and works with coworkers and leadership resources to suggest process improvements
• Maintains CPhT certification through continuing education via CE Credits to ensure accuracy, consistency, and knowledge of current pharmacy practices/drug changes.
  *If currently certified/licensed
• Effectively documents all service interactions with customers within appropriate systems according to guidelines
• Develops and maintains behaviors of productivity, availability to customers, and adherence to work schedule.

Qualifications

• Required High School Diploma or equivalent
• Preferred Associate's Degree

• 1 year of relevant experience customer-facing service on phone or face to face; customer service, high volume call center, insurance environment relevant to benefits, and/or managed health care Required
• 2 years of relevant experience Pharmacy technician experience, pharmacy billing/claim adjudication Required

• CRT-Pharmacy Technician, Certified (CPHT) - PTCB Pharmacy Technician Certification Board Upon Hire preferred Or
• LIC-Pharmacy Technician - STATE_MI State of Michigan Upon Hire preferred Or

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Pharmacy Contact Center

Employment Type

Full time

Shift

Weekly Scheduled Hours

40

Hours of Work

Variable

Days Worked

Variable

Weekend Frequency

Variable weekends

Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

category. See more here.