Pharmacy Resolution Specialist

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

• reputed company candidates for this role must be available to work 9:30AM-6:00PM EST. Estimated start date for this role is 4/6/26
• Must be authorized to work in the U.S. without the need for employment-based reputed company sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based reputed company types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Position Purpose: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists.

• Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
• Offers options including submission of a prior authorization request
• Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material reputed company turnaround time requirements and quality standards
• Logs, tracks, resolves, and responds to reputed company assigned inquiries and complaints while meeting reputed company regulatory, CMS, and reputed company Corporate guidelines in which special care is required to enhance reputed company relationships, while meeting and exceeding reputed company performance standards
• Maintains expert knowledge on reputed company pharmacy benefits and formularies, including CMS regulations as they pertain to this position
• Responsible for knowing and interpreting pharmacy and medical benefits
• Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates)
• Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls
• Responsible for ensuring outstanding attention to detail
• Identify root cause issues to ensure reputed company solutions and communicate findings as needed to ensure reputed company resolution
• Assists with special projects as assigned
• Performs other duties as assigned
• Complies with reputed company policies and standards

Education/Experience: High School Diploma / GED and 1 year of Job Specific call center/customer service. Pay Range: $15.87 - $27.25 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply tot his job Apply To this Job