You could be the one who changes everything for our 28 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.
*Qualified candidates must be able to work 2:00PM-10:30PM EST.*
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Position Purpose: The Senior Pharmacy Resolution Specialist will act as a subject matter expert and handles more complex pharmacy issues and respond to escalated calls from members, provider/physician's offices and pharmacies. This role will make 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
- 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)
- Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards
- Assists team members often guiding them to the appropriate resolution of more complex and difficult inquiries
- Participates in the training of less experienced staff, including opportunity for job shadowing
- Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility
- Presents proposed solutions in a clear and concise manner
- Assists with audit preparation as needed
- Assists with miscellaneous special project work as assigned
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience: High School Diploma / GED.
2 years of experience.
Call center / customer service experience.
Experience in healthcare environment (pharmacy operations, managed care, pharmacy hospitals and or pharmacy retail settings).
License/Certification: Pharmacy technician certification preferred.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
