First day will consist of Introduction to team and Pharmacy systems
Internal/External Groups with which the Candidate will interface: Pharmacy Team, Quality Team, External Provider Groups, External Pharmacies, Members
The team has had success with previous temps across our organization
These adherence calls will help support Medicare star rating
For Ambetter it will assist in quality rating
Key Responsibilities:
Receive and respond to provider and pharmacy calls regarding the prior authorization and formulary process
Perform review of pharmacy and override process in compliance with pharmaceutical related company and State guidelines
Track and trend overrides to ensure criteria have been met, audit for prior authorizations, analyze cost and determine utilization patterns
Resolve complaints and grievances related to the pharmacy network in conjunction with the Pharmacy team
Assist Provider Relations and various departments with educating providers on the health plan's pharmacy process
Assist with the pharmacy utilization review and reporting process
Collaborate with Quality Improvement department with various meeting preparation and transcription of minutes
Assist with members' inquiries related to the formulary process
Performs other duties as assigned
Complies with all policies and standards
Employee will be responsible for making outbound calls to members, providers, and pharmacies regarding medication refills and for resolution of adherence barriers
Employee will be evaluated on:
of calls made per day/week
of successful fills and 30-90-day conversions
Thorough member follow-up and documentation
Call audits
Qualification & Experience:
High school diploma or equivalent
3+ years of pharmacy experience, preferably in a managed care environment
Medicare and/or Medicaid experience preferred
Previous experience in call center or fast paced pharmacy answering multi-line phone system preferred
Prior experience using analysis tools or systems (ex: web based, custom, proprietary, etc.)
Experience in the implementation of quality process improvement efforts
Experience documenting requirements, creating training materials and working directly with end users
License/Certificate: Current state's Pharmacy Technician license and Pharmacy Technician Certification Board (PTCB) or the ability to obtain both license and PTCB within 30 days of the start date (for general and Superior Health Plan); Current Arizona Pharmacy Technician license (for Arizona Complete Health); Current state's Pharmacy Technician license preferred (for our organization's Pharmacy Services)
Advanced Microsoft office experience preferred (Excel, Word, Teams, Outlook)
Excellent verbal and written communication skills
Bilingual (Spanish) preferred
Disqualifiers: Poor communication/customer service skills (position will be outbound call-based)
Spectraforce Technologies
Jun 16, 2025