Pharmacy Benefits Specialist I

The Population Health Specialist II provides operational support for the Case, Condition Management, Quality, Wellness, Pharmacy, Government Relations, and Utilization Management Departments including requesting and extracting medical records and provider outreach for HEDIS, Health Risk Assessments, Primary Care Provider Attributions, and CIOX medical records. This role assists with supporting and monitoring compliance with CMS federal regulatory and NCQA standards related to the authorization process. The Population Health specialist II may also be responsible for various outbound member calls, including new welcome calls, service recovery opportunities, etc.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at our office in Menasha, or a combination of in person and at your home office (reliable internet is required) with our hybrid workplace model.

Hours: 1.0 FTE, 40 hours per week, 7:30am - 5pm Monday through Friday

Check out our 2024 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

• Maintain department websites - after Pharmacy & Therapeutics
• Manage large mailings including letter preparation, mail merge and distribution
• Create and maintain Prescription Benefit Summary of Member Responsibility Tables
• Provide a variety of reports for internal and external stakeholders including Prior Authorization, physician utilization, Controlled Substance Reporting, Annual Quality Improvement Program Evaluation, call log and drug reports related to Key Performance Indicator Board, and work with Sales to run standard reports from Pharmacy Benefits Manager (PBM)
• Complete files reviews for denials
• Maintain J-Code Tier Levels billing tables for claims
• Answer formulary status questions for Commercial and Medicare Sales, and Customer Service
• Assist Care Management/Disease Management with benefit questions, Prior Authorization requirements, and grievances
• Pull data for reporting pharmacy trends
• Manage the PBM Satisfaction Survey process
• Research and resolution of benefit issues
• Benefit testing
• Other duties and responsibilities as assigned

Job Requirements:

• High School Diploma required
• One year of experience in a Pharmacy Tech position or one year of experience working with pharmacy benefits required
• Certified Pharmacy Technician preferred
• One (1) year of experience working with pharmacy benefits may substitute for certification

Network Health is an Equal Opportunity Employer