Lead Pharmacy Operations Specialist

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

Reporting to the Manager of Pharmacy Support Operations, the Lead Pharmacy Operations Specialist is responsible for activities ranging in scope from prior authorization processing to stepping in to assist in the absence of the Manager of Pharmacy Support Operations. The Lead Specialist supports all Operations Specialist staff in meeting individual goals as well as department level metrics and goals. S/he works closely with the management team, assists with quality control when needed, and responds to pharmacy related inquiries. The Lead Specialist assists with systems testing and troubleshoots system issues across multiple platforms. S/he will also meet established performance metrics, as well as assist teammates in achieving these goals.

The Lead Specialist mentors and coaches Pharmacy Operations Specialists, fosters an environment of professionalism and teamwork and is a front line resource for all team members. S/he will encourage and develop a strong working relationship with the Pharmacy Operations staff, act as a subject matter expert for prior authorization processing, pharmacy systems and other Pharmacy Operations clinical, contractual and regulatory requirements. The Lead Specialist will be engaged, open to answering questions, a positive role model, and convey a willingness to contribute to the success of their teammates, management team and the Pharmacy Operations department.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

* Demonstrates expert knowledge and understanding of Pharmacy Operations policies and procedures, in addition to all clinical, contractual and regulatory requirements as they influence, or relate to pharmacy.

* Serves as a subject matter expert and first line for escalated issues for Operations Specialists in the day-to-day operations of the department. Exercises good judgment and involves the Manager or Senior Manager as necessary.

* Interprets and processes complex prior authorization requests for pharmacy and medical drugs.

* Performs peer audits including quality review and new employee mentoring.

* Attends interdepartmental meetings and participates in cross-functional initiatives on behalf of the department when needed.

* Demonstrates working knowledge of systems and platforms leveraged to conduct prior authorization reviews for pharmacy and medical drugs.

* Maintains quality and performance levels set for Pharmacy Operations Specialists while coordinating special team projects. Including, but not limited to,

* Receive, process, and review all prior authorization requests received through fax, phone, or electronic prior authorization systems in accordance with all regulatory and accreditation requirements.

* Properly apply clinical policy criteria to the review of prior authorization requests

* Review and interpret member's eligibility, claim history, and Pharmacy Program information using the PBM claims software to provide information to both internal and external clients via telephone or email

* Interprets medical and pharmacy data and accurately enters information into system according to regulatory and NCQA accreditation requirements

* Communicate determinations to members and providers via incoming and outgoing telephone calls, fax notifications, and letter notifications

* Serves as a backup for the Pharmacy Operations Support Manager as needed.

* Tests system changes and operational enhancements.

* Serves as a first-line agent on escalated calls/issues when necessary

* Other duties as assigned by department Supervisors.

Supervision Exercised:

* Occasional supervision, or training, of Pharmacy Operations Specialists

Supervision Received:

* Direct supervision received weekly.

Qualifications:

Education Required:

* Minimum of a High School diploma or equivalent required. Associate or Bachelor's degree preferred

Experience Required:

* Two or more years of experience in a professional or pharmacy setting is required

* Two or more your experience in prior authorization processing is required

* Previous experience in a managed care environment preferred

* Certified pharmacy technician preferred

* Previous experience engaging in management activities preferred

* Prior experience engaging in projects preferred

* Prior customer service experience preferred

Required Licensure, Certification or Conditions of Employment:

* Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

* Excellent Customer Service skills

* Prior experience assisting members and/or providers with telephone inquiries

* Strong organizational, problem solving, communication, and interpersonal skills

* Excellent written and oral communication skills required.

* Must have strong data entry and attention to detail in building cases

* Must be able to multitask and be results oriented

* Working Conditions and Physical Effort:

* Regular and reliable attendance is an essential function of the position.

* Ability to work in a fast-paced environment.

* Work is normally performed in a typical interior/office work environment.

* No or very limited physical effort required. No or very limited exposure to physical risk.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees