• Customer Service and Claims Processing • Communicate in a professional and respectful manner • Maintain confidentiality within HIPAA regulations and function on “need to know” principles • Respond to drug coverage inquiries in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff • Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies • Document all customer service activities according to organization requirements • Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit • Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance • Data Entry and Clerical Support • Sort incoming faxes and distribute according to assignments • Maintain files according to unit protocols • Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned. • Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports. • Prior Authorizations (PA) and Formulary Exceptions • Verify member’s plan eligibility and applicable benefit for drug coverage • Review member’s medication and eligibility history, load authorization in claim adjudication platform(s) • Assist members and providers with the PA, formulary exception and coverage determination process • Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determination requests • Notify members, providers or providers staff of prior authorization and formulary exception decisions • Appeals and Grievances • Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff • Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances • Project Coordination • Minimal project participation