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The Pharmacy Resolution Specialist responds to escalated issues from both provider/physician’s offices and pharmacies received through transferred phone calls and customer service management and resolves those issues. Enters pharmacy overrides into the PBS/RXClaims system based on approved guidelines and approvals from Clinical Pharmacists. Makes out bound calls to physicians and pharmacies. Responsibilities also include miscellaneous special project work.
Log, track, resolve and respond to all assigned inquiries and complaints while meeting all regulatory, CMS, and WellCare Corporate guidelines in which special care is required to enhance WellCare relationships; while meeting and exceeding all performance standards.
Enters DER overrides into the PBS/RXClaims system on a timely basis.
Identify root cause for pharmacy claims issues and assist pharmacies in getting claims processed, so member can receive their medication.
Follows pharmacy guidelines to make decisions on drug overrides for vacations, refill too soon and emergency request.
Accurately take verbal DER and appeals request.
Ability to follow directions.
Assists with special projects as assigned or directed.
Required A High School or GED
Preferred An Associate's Degree in a related field
Required 1 year of experience in In a call center or customer service environment.
Preferred 1 year of experience in Experience in healthcare environment (pharmacy operations, managed care, hospitals and/or retail environments).
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Beginner Other Ability to use pharmaceutical references.
Beginner Other Ability to evaluate information from both oral and written sources, pharmaceutical references and report information to pharmacists.
Beginner Other Working knowledge of prescription medications and pharmacotherapy.
Intermediate Other Ability to follow direction.
Licenses and Certifications:
Required Intermediate Microsoft Word Knowledge of Microsoft Office including Word, Excel and Power Point
Required Intermediate Microsoft Excel Capable of learning to use Sidewinder, Crystal and WHI Data bases
Required Intermediate Microsoft Outlook
Required Beginner Healthcare Management Systems (Generic)