Inpatient Hospital Auditor II

About the position The Pharmacy Specialist II position is a critical role within Horizon BCBSNJ, responsible for managing prior authorization requests from pharmacists, physicians, and patients. This position plays a vital part in the coordination of Pharmacy Services activities, which include claim utilization analysis, prescription plan design, ad-hoc reporting, and correspondence related to special projects. The specialist must ensure compliance with organizational goals and regulatory standards while maintaining high performance levels. Additionally, this role serves as a backup for the department supervisor when necessary. In this role, the Pharmacy Specialist II will process prior authorizations received through the help line, evaluating the medical necessity and appropriateness of specific drugs based on established medical criteria. The specialist will engage directly with members, physician office staff, pharmacies, and internal stakeholders to address eligibility, coverage determinations, and claims issues. Recommendations for improving departmental efficiency, accuracy, and productivity will be a key responsibility, alongside processing appeals, complaints, and compliance-related issues. The specialist will also be tasked with researching, recommending, and implementing procedures to enhance departmental operations, including providing pharmaceutical information to support market business units and provider service areas. Participation in training sessions for clients, members, and employees is expected to ensure a comprehensive understanding of pharmacy services programs and operations. Monitoring day-to-day workflow metrics and coaching new employees are additional responsibilities that contribute to the overall success of the department. Responsibilities • Process prior authorizations received via the help line, evaluating medical necessity for specific drugs. , • Interact with members, physician office staff, pharmacies, and internal stakeholders for eligibility and claims issues. , • Provide recommendations to increase efficiency, accuracy, and productivity in the department. , • Process appeals, complaints, executive inquiries, and compliance-related issues. , • Research, recommend, monitor, develop, and implement procedures to enhance departmental efficiency. , • Process ad hoc requests for information or reports from various stakeholders. , • Participate in client member and employee training on pharmacy services programs. , • Monitor day-to-day workflow metrics and formulate strategies for improvement. , • Coach and train new employees and act as backup to the Pharmacy Benefit Analyst or supervisor. , • Assist in resolving Physician/Member requests in a timely manner. Requirements • Bachelor's degree in Health Care Management, Business, or Pharmaceutical Administration preferred. , • Minimum of two years experience in third party prescription program claim adjudication required. , • Minimum of two years experience as a Pharmacy Utilization Management Specialist required. , • Prior customer service/service quality initiative experience required. , • Pharmacy Certification required. , • Knowledge of popular brand and generic drug names required. , • Knowledge of third party prescription program claim adjudication required. , • Working knowledge of managed care principles required. , • Knowledge of common medical terminology required. , • Understanding of National Drug Code (NDC) required. , • Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation required. , • Ability to utilize a personal computer and applicable software required. , • Effective verbal and written communication skills required. , • Ability to work well within a team and deliver technical information to less technical individuals required. , • Proven time management skills and ability to manage multiple priorities required. , • Ability to exercise sound judgment and strong problem-solving skills required. Nice-to-haves Benefits • Comprehensive health benefits (Medical/Dental/Vision) , • Retirement Plans , • Generous PTO , • Incentive Plans , • Wellness Programs , • Paid Volunteer Time Off , • Tuition Reimbursement Apply Job!