Pharmacy Benefit Specialist II

We need to output HTML fragment with headings

for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title. Must not include Job ID etc. Must preserve all substantive info, no invention. Remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning, duplicated lines, application instructions. Also remove "Current CareOregon Employees: Please use the internal Workday site to submit an application for this job." Also remove "Please contact your recruiter for more information." Also remove EEO statements. Also remove. We need to parse the posting. Let's extract sections: First paragraph: "This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation. This is a M-F position. Estimated Hiring Range $25.92 - $31.68 Bonus Target Bonus - SIP Target, 5% Annual" That gives about role, schedule (M-F), pay range, bonus. Then "Essential Responsibilities" heading then list of responsibilities broken into categories: Customer Service and Claims Processing, Data Entry and Clerical Support, Prior Authorizations (PA) and Formulary Exceptions, Appeals and Grievances, Project Coordination. Then "Required Experience and/or Education" then bullet list. Then "Preferred" list. Then "Knowledge, Skills And Abilities" with Required Knowledge, Skills And Abilities. Then "Working Conditions" with details. Then "We offer a strong Total Rewards Program..." benefits description. We need to map to sections: - About the role: could be the first paragraph describing purpose. - Responsibilities: list of duties (the essential responsibilities sections). Should be a

• list. - Requirements: maybe "Required Experience and/or Education". Could be Requirements. - Qualifications: maybe "Preferred" items? Or could combine. But we need to decide. The instruction: use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can have separate sections for Requirements, Qualifications, Skills. We need to decide what content goes where. We have "Required Experience and/or Education" -> Requirements. We have "Preferred Pharmacy Technician Certification (CPhT) Pharmacy Technician experience Pharmacy related outbound calls experience" -> Qualifications (preferred qualifications). We have "Knowledge, Skills And Abilities" -> Skills section. We have Benefits description -> Benefits. We have Pay and Bonus -> Pay section. We have Schedule: "This is a M-F position." Also maybe mention work from home? That's location but schedule is M-F. So Schedule section. We also have Working Conditions details (Work Environment, etc.) Could be part of About the role? Or maybe we could include as a separate section but not in prescribed headings. Since only those headings allowed, we should incorporate working conditions into About the role or Responsibilities? Probably About the role can include work environment. But we must not invent sections. We could add a short paragraph under About the role covering work location and conditions. We must not include boilerplate like EEO etc. We must preserve all substantive info. So we need to include details like: "Work from home", "Indoor/Office", "Member/Patient Facing: No", "Hazards: May include, but not limited to, physical and ergonomic hazards.", "Equipment: General office equipment", "Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used." Also "Work Location: Work from home". Also "We offer a strong Total Rewards Program..." benefits details. We need to ensure we don't repeat info unnecessarily but preserve all. Let's extract each piece. First paragraph: "This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. Core responsibilities include customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation. This is a M-F position. Estimated Hiring Range $25.92 - $31.68 Bonus Target Bonus - SIP Target, 5% Annual" We'll split: About the role: first sentence maybe. Responsibilities: core responsibilities list. Pay: Estimated Hiring Range $25.92 - $31.68 Bonus Target Bonus - SIP Target, 5% Annual. Schedule: This is a M-F position. Now essential responsibilities details: we need to list each duty as bullet points. Could group under subheadings? But we only allowed

  for sections; we can still have

  • inside responsibilities section. We can include all duties as list items, maybe grouping with sub-bullets? Simpler: just list each responsibility as a separate
  • . Must preserve all details. Let's extract each bullet from the essential responsibilities: Under Customer Service and Claims Processing: - Communicate in a professional and respectful manner. - Maintain confidentiality within HIPAA regulations and function on “need to know” principles. - Respond to drug coverage inquires in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff. - Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies. - Document all customer service activities according to organization requirements. - Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit. - Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance. Data Entry and Clerical Support: - Sort incoming faxes and distribute according to assignments. - Maintain files according to unit protocols. - Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned. - Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports. Prior Authorizations (PA) and Formulary Exceptions: - Verify member’s plan eligibility and applicable benefit for drug coverage. - Review member’s medication and eligibility history, load authorization in claim adjudication platform(s). - Assist members and providers with the PA, formulary exception and coverage determination process. - Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. - Notify members, providers or providers staff of prior authorization and formulary exception decisions. - Perform prior authorization reviews with pharmacist oversight. Appeals and Grievances: - Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff. - Perform intake of member and provider appeals & reconsiderations, gather data & documentation and prepare appeals for review by CareOregon Pharmacists & Medical Directors. - Complete pharmacy appeals and notify members and providers of outcome. - Assist the Appeals & Grievance Coordinators, Pharmacists, Medical Directors and Quality Improvement Coordinators with processing pharmacy benefit appeals and grievances. Project Coordination: - Under the supervision of a pharmacist and/or the operations supervisor, assist with pharmacy benefit projects including, but not limited to process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach. Now Required Experience and/or Education: - Minimum 2 years work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 2 years’ experience in a health insurance plan - Minimum 1 year experience with managed care and/or pharmacy benefit management Preferred: - Pharmacy Technician Certification (CPhT) - Pharmacy Technician experience - Pharmacy related outbound calls experience Knowledge, Skills And Abilities: Required Knowledge: - Advanced knowledge of medical and pharmaceutical terminology - Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts Skills And Abilities: - Proficient with Microsoft Office Products and general computer literacy - Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities - Ability to follow and provide input into policies and procedures in performing job responsibilities - Advanced listening, verbal, and written communication skills - Ability to exercise professionalism - Proficient ability to network and utilize internal and external resources - Ability to focus on and comprehend information - Ability to learn new skills and abilities - Ability to assess a situation and seek or determine appropriate resolution - Ability to accept managerial direction and feedback - Ability to tolerate and manage stress - Results and service oriented - Ability to be flexible and adaptable - Ability to organize, plan, and prioritize daily workflow and projects within time constraints - Ability to work in an environment with diverse individuals and groups - Ability to work independently with minimal supervision - Ability to learn, focus, understand, and evaluate information and determine appropriate actions - Ability to accept direction and feedback, as well as tolerate and manage stress - Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day - Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions: - Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure - Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person - Hazards: May include, but not limited to, physical and ergonomic hazards. - Equipment: General office equipment - Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. - Work Location: Work from home Benefits: - We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. - Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. - Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. - CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). - We also offer a strong retirement plan with employer contributions. - Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. - Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. - Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. We need to exclude duplicated lines and boilerplate. The duplicated lines: maybe "Ability to accept direction and feedback, as well as tolerate and manage stress" appears twice? Actually appears once in Skills And Abilities list and also later? Let's check: In Skills And Abilities list we have "Ability to accept managerial direction and feedback" and later "Ability to accept direction and feedback, as well as tolerate and manage stress". Those are distinct but similar. We'll keep both as they are separate statements. We also have "Ability to tolerate and manage stress" appears twice? Actually earlier: "Ability to tolerate and manage stress" appears in list after "Ability to accept managerial direction and feedback". Then later "Ability to accept direction and feedback, as well as tolerate and manage stress". So we have both; keep. Now we need to output HTML fragment only, no markdown fences. We'll structure:

    About the role

    This position is responsible for working with CareOregon members, their providers, and