Job description

You could be the one who changes everything for our 26 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.

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

Education/Experience: High School Diploma / GED 1 year of Job Specific call center/customer service Computer skills- Microsoft office, typing Ability to evaluate information from both oral and written sources, pharmaceutical references Ability to follow direction

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.

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