Description :

Responsible for expeditious and accurate adjudication of pharmacy claims, and the provision of excellent customer service to all members, employer groups, providers and other departments or teams.

Rotates between pharmacy claims and customer service responsibilities and acts as a subject matter expert in both of these areas.

Acts as a mentor to other staff as directed by department leadership.

Job Essentials :

• Processes and / or communicates multiple types of pharmacy benefits including coordination of benefits, direct member reimbursements, coinsurance benefits, and mail order prescriptions.
• Receives incoming calls from members, providers, facilities, employer groups, and other departments. Provides superior customer service that is consistent with policies, company values, and quality standards.
• Educates callers on correct use of their plans, including coverage of benefits, utilization, and administrative guidelines, in collaboration with teammates and other departments.

Makes exception / empowerment decisions within the established exception policy.

• Consistently demonstrates excellent customer service skills including problem solving, telephone etiquette, and responsiveness to customers.
• Ensures that all department phone standards and expectations are met pertaining to call statistics, production, documentation, and quality / accuracy.
• Efficiently and quickly addresses and solves problems on phone calls.

Acts as a mentor and willingly coaches and develops others under the direction of the team supervisor and trainer, and provides effective feedback to other Pharmacy Benefits Specialists as needed.

• Meets or exceeds department standard for call time and answered call percentage in relation to the team average.
• Efficiently and accurately enter overrides for pharmacy claims. Meets or exceeds department standards for override audits.
• When assigned, assists in the payment of claims for both members and pharmacies while maintaining accuracy standards.
• Completes and analyzes specialized reports that are used to ensure timely and accurate claims adjudication.
• Works closely with the operation and pharmacy teams to educate the staff and resolve problems.
• Maintains the confidentiality of member's personal information to be compliant with internal confidentiality policy. Maintains customer history in member tracking using correct codes and detailed comments.
• May help on help desk calls as department needs dictate.

About TEKsystems :

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity.

We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia.

As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change.

That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

Last updated : 2024-03-23