Job description

You could be the one who changes everything for our 26 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.

Position Purpose: This role will focus on ensuring that the administration of the pharmacy program is accurate and compliant by supporting various operational tasks.

Formulary Management:
Reviews and processes formulary change requests from Health Net plans
Submits and maintains formulary change requests to Health Net’s pharmacy claims processor
Generates, maintains and reviews Formulary Status Grids
Uses reports to perform audits and quality checks on the current formulary status for accuracy and contract compliance
Assists Clinical Pharmacist with formulary database maintenance and updates to company web site

Pharmacy Audit and Recovery:
Performs a variety of assignments required for pharmacy audit and recovery functions.
Reviews paid claims for quantity and/or billing discrepancies. Corresponds with pharmacies as needed to communicate review finding.
Faxes inquiries to pharmacies related to review findings
Answers in-coming calls and responds appropriately to faxed correspondence from pharmacies
Updates Access database with incoming phone calls, faxes and e-mails

Pharmacy Services Center:
Takes member inquiry calls for benefit questions including prior authorization requests
Maintains expert knowledge on all Health Net Medicare Pharmacy benefits and formularies, including CMS regulations as they pertain to this position.
Educates the member on their specific pharmacy benefit and offers them options including the submission of a prior authorization request.
Process member submitted claims.

Prior Authorization:
Reviews requests made by physicians and pharmacies for use of prescription drugs that are non-formulary, have prior authorization requirements, have exceeded quantity or cost limits, or require assistance in on-line processing of a prescription claim.
Assign, enter and document prior authorizations into appropriate claims processing system.
Answer phone calls for prior authorization inquiries
Researches and resolves issues using the appropriate reference material.
Responsible for knowing and interpreting pharmacy and medical benefits.
Medicare Part D Operations
Reviews and processes PDE files
Researches and resolves issues using the appropriate reference material
Assists in pharmacy claims corrections projects
Performs audits and quality checks on active prior authorizations claims
Assists with identifying and correcting eligibility and group issues
Processes member claims
State Health programs Pharmacy Operations
Liaison to internal and external departments for SHP pharmacy
Operational issue resolution, including issues from Prior Auth, Appeals and Grievances, and
Member/Provider Services
Preparation and review of various operational reports and audits
SHP formulary management functions, including quarterly formulary updates to website, database and benefit maintenance
Maintenance of prior authorization database files
Medi-Cal DMR processing
Assist with SHP clinical projects
Assist with Medi-Cal prior authorizations
Oversight and Audit Support
Assists in the implementation of regulatory changes
Participates in maintaining consistent processes/methods for development, implementation, communication and training on new/updated policies and procedures
Participates with Business Units/departments with an end-to-end process orientation to ensure appropriate connectivity and handoffs are built into P&Ps that span multiple departments
Provides support and monitoring to ensure compliance of First Tier, Downstream and Related Entities (FDRs)
Assists with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)

Education/Experience:
High School Diploma or GED
2+ years of pharmacy experience, preferably in managed care environment
Excellent verbal/written communication skills, strong problem solving and analytical skills required. Ability to manage deliverables in a high pace environment.

License/Certification:
Current state’s Pharmacy Technician license preferred

Pay range: $18.26 to $31.10

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. The employee may be eligible for bonuses and other forms of compensation

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

Pay Range: $18.27 - $31.10 per hour

jackharris.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, jackharris.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, jackharris.com is the ideal place to find your next job.