Job Title: Pharmacy Services Specialist

Location: Remote must be in approved states (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming)

Shift timings: Hours 8 am to 5 pm EST (with 1 weekend a quarter once fully trained up)

Duration: 6 months to start with the possibility of extension or conversion based on the needs of the business.

Spotlight Notes

This role is non-clinical, reviewing online/fax requests for prescription pre-authorization to ensure all needed details are submitted. If any item/field is missing the authorization will be denied.
Hours are M-F 8 a.m. to 5 p.m. with 1 weekend a quarter once fully trained up.
The expectation is a minimum of 7 cases reviewed per hour; strong resources work up to about 14 cases reviewed hourly.
All cases are audited for Quality of 98% w/o error and Production.
Que is based in MHK.
Prime Theraputics and pharmacy experience are preferred but not required.
Resources are not required to work holidays the FTE's are on schedule for holidays.
Candidates need to have a strong attention to detail, and be critical thinkers, and able to handle. working remotely while staying on task.
No request are by phone.
Internet speed test needs to be included with all submittals.

Intake Notes:

6-month project to start with the possibility of extension or conversion based on the needs of the business.
Candidates need to have experience in Prime, will be working within Genesis, MHK, CareRadius, and MS Office.
Candidates need to be able to work within multiple programs.

Job Description:

Provides daily coordination of activities related to operations of pharmacy benefit management.
Provides support to staff and coordinates tasks regarding the research, development, implementation and evaluation of programs, projects and initiatives.
Serves as resource to staff and subject matter expert for assigned initiatives to provide input regarding pharmacy needs, impacts and projects.
Resolves issues and escalates to management as appropriate; assists management in addressing clinical and contractual issues.
Coordinates review, implementation, and quality assurance of benefit plan administration with internal stakeholders and PBM account team.
Resolves or coordinates the resolution of escalated customer service inquiries and grievances internally and with PBM, including researching and authorizing/making pharmacy claim adjustments as appropriate.
Coordinates the resolution of Pharmacy Coverage Determinations with Clinical Staff and/or external partners as appropriate.
Coordinates the resolution of pharmacy claim reconsiderations and appeals with the Appeals department and/or external partners as appropriate.
Responsible for responding to and coordinating review and approval of RFPs, government program applications, and similar requests.

Hiring Requirements:

High school diploma or GED.
3+ years of experience in related field.

About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com

Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.

California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com .

LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer.

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Pharmacy Services Specialist