Employer Industry: Health Insurance

Why consider this job opportunity:
- Salary up to $58,800
- Comprehensive health benefits (Medical/Dental/Vision)
- Generous PTO and paid volunteer time off
- Opportunity for professional development through tuition reimbursement
- Incentive plans and wellness programs to support employee well-being
- Work within a collaborative and innovative environment dedicated to improving member health

What to Expect (Job Responsibilities):
- Manage telephonic interactions with members, physicians, pharmacies, and internal teams regarding pharmacy eligibility and coverage determinations
- Engage with healthcare providers to conduct clinical interventions and ensure formulary compliance
- Collect and evaluate clinical information for prior authorization requests to determine medical necessity
- Handle complaints, appeals, grievances, and compliance-related issues effectively
- Identify potential instances of fraud, waste, and abuse during member and provider interactions

What is Required (Qualifications):
- High School Diploma or GED required
- Minimum of two (2) years of experience as a Pharmacy Technician
- Experience in customer service and service quality initiatives
- National Pharmacy Technician Certification (PTCB or ExCPT) required, or a minimum of 5 years of relevant pharmacy experience
- Knowledge of third-party prescription program claim adjudication and common medical terminology

How to Stand Out (Preferred Qualifications):
- Minimum of two (2) years of experience in third-party prescription program claim adjudication
- Familiarity with managed care principles and State of New Jersey Board of Pharmacy regulations
- Proven ability to deliver technical information to non-technical individuals
- Experience working in a production-focused environment
- Strong problem-solving skills and ability to manage multiple priorities

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