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 if posting has real specific content. We must not repeat job title as heading. No Job ID etc. Remove boilerplate, navigation, EEO, etc. Must preserve all substantive info. We need to parse the posting. Key content: - Position description: "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" - Essential Responsibilities: list of bullet-like items under categories: Customer Service and Claims Processing, Data Entry and Clerical Support, Prior Authorizations (PA) and Formulary Exceptions, Appeals and Grievances, Project Coordination. - 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: list many items. - Working Conditions: Work Environment(s): Indoor/Office; Member/Patient Facing: No; Hazards: may include physical and ergonomic hazards; Equipment: General office equipment; Travel: occasional required or optional travel; 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." - EEO boilerplate: remove. - Application instructions: "Current CareOregon Employees: Please use the internal Workday site to submit an application for this job." Also "Please contact your recruiter for more information." Remove application instructions. - Also "Estimated Hiring Range $25.92 - $31.68 Bonus Target Bonus - SIP Target, 5% Annual" This is pay info. - Schedule: "This is a M-F position." So schedule: Monday-Friday. - Also "Work Location: Work from home" could be part of Working Conditions but not a separate section. We need sections: About the role (maybe a brief summary), Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must not create sections with placeholder text. So we need to ensure each section has substantive content. Let's decide: - About the role: Could be the first paragraph describing purpose: "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." That's substantive. - Responsibilities: list of core responsibilities and essential responsibilities broken down. Use

• . - Requirements: maybe "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". That's requirements. - Qualifications: maybe "Preferred Pharmacy Technician Certification (CPhT); Pharmacy Technician experience; Pharmacy related outbound calls experience". Could be qualifications. - Skills: list of Knowledge, Skills And Abilities. - Benefits: detailed benefits description. - Pay: "Estimated Hiring Range $25.92 - $31.68 Bonus Target Bonus - SIP Target, 5% Annual". That's pay. - Schedule: "This is a M-F position." Also maybe mention work from home? But schedule is M-F. We must not include sections like "Working Conditions" unless we map to something else. Not required headings list includes Working Conditions not in allowed headings, so we should not create a section for it. However we could incorporate some info into Responsibilities or About the role? Probably better to omit working conditions details as they are not required headings; but we must preserve ALL substantive information. The instruction says "Preserve ALL substantive information; do NOT invent or summarize away detail." So we cannot drop substantive info like working conditions. However we can embed them within existing sections if they fit. For example, we could add a short paragraph under Responsibilities about work environment? Or maybe we can create a section "Working Conditions" but it's not in the allowed headings list. The instruction says: "Use

  for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It gives examples but does not explicitly forbid other headings? It says use

  for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). Likely they expect only those headings. So we must fit all substantive info into those sections. Thus we need to incorporate working conditions info into maybe Responsibilities or About the role. For example, we could add a sentence: "Work is performed indoors in an office setting, primarily remote (work from home), with occasional travel." That preserves info. Similarly, we need to incorporate Hazards, Equipment, Travel, Work Location. We'll embed them in About the role or Responsibilities. Now we need to ensure we don't repeat job title as heading. No job title given explicitly; we can ignore. Now produce HTML fragment. Structure:

  About the role

  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. Work is performed indoors in an office setting, primarily remote (work from home), with occasional travel required or optional. The role involves customer service, claims processing, prior authorizations, formulary exceptions, appeals, grievances, and project participation, and is scheduled Monday‑Friday.

  Responsibilities

  • 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 inquiries accurately and timely 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 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.
    • Provide clerical assistance for pharmacy projects, including 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 provider 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 process improvements, cost saving initiative projects, benefit implementation/changes, and member/provider/pharmacy outreach.
  But we have nested lists; the instruction says use
  • for any list of duties/requirements/benefits. It didn't forbid nested lists, but we could flatten. However nested lists are still
    • . It's okay. Alternatively we could make each top-level item a
    • with a heading inside. But okay. Now Requirements:

      Requirements

      • 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.
      Qualifications:

      Qualifications

      • Preferred Pharmacy Technician Certification (CPhT).
      • Pharmacy Technician experience.
      • Pharmacy‑related outbound calls experience.
      Skills:

      Skills

      • Advanced knowledge of medical and pharmaceutical terminology.
      • Substantial understanding of managed care, Medicare, and Oregon Health Plan concepts.
      • 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.