Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

This position is responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including claim utilization analysis, prescription plan design, ad-hoc reporting, correspondence and special projects. This position must ensure performance is in compliance with organizational or departmental goals and in compliance with regulatory agencies. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs and based on clinical criteria.

What You'll Do

• Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues.

• Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design.

• Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination.

• Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied

• Process complaints, appeals, grievances, executive inquiries and compliance related issues.

• Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary.

• Provide recommendations to increase efficiency, accuracy and productivity in the department.

• Process ad hoc request for information or reports from stakeholders.

• Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows.

• Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program.

• Provide support to various clinical programs within the pharmacy department.

What You Bring

Education/Experience:

• High School Diploma/GED required

• Requires minimum of two (2) years experience as a Pharmacy technician

• Prefers minimum of two (2) years experience in third party prescription program claim adjudication.

• Requires prior customer service/service quality initiative experience.

Additional licensing, certifications, registrations:

• Requires National Pharmacy Technician Certification (PTCB or ExCPT)

• In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required.

Knowledge:

• Requires knowledge of popular brand and generic drug names.

• Requires knowledge of third party prescription program claim adjudication.

• Requires working knowledge of managed care principles.

• Requires knowledge of common medical terminology.

• Requires understanding of National Drug Code (NDC).

• Requires knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation.

Skills and Abilities:

• Requires the ability to utilize a personal computer and applicable software.

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.

• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.

• Demonstrated ability to work in a production focused environment.

• Proven ability to exercise sound judgment and strong problem solving skills.

• Proven ability to ask probing questions and obtain thorough and relevant information.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$44,600 - $59,745

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.