100% Remote for NJ candidate with NJ Active license

• Responsibilities:
• Process prior authorizations received via helpline, evaluating medical necessity for specific drugs based on medical criteria.
• Interact with members, physician office staff, pharmacies, and internal stakeholders for eligibility, coverage determination, and claims issues.
• Conduct interventions to promote formulary compliance and generic dispensing.
• Process appeals, complaints, executive inquiries, and compliance-related issues.
• Provide recommendations to improve department efficiency, accuracy, and productivity. Assist in day-to-day pharmacy department functions and Medication Therapy Management program.
• Support various clinical programs within the pharmacy department.
• Participate in client, member, and employee training on pharmacy services programs and operations.
• Education Qualification:
• Bachelor's degree in Health Care Management, Business, or Pharmaceutical Administration preferred.
• Minimum of two (2) years of experience in third party prescription program claim adjudication.
• Minimum of two (2) years of experience as a Pharmacy Utilization Management Specialist. Prior customer service or service quality initiative experience is required.