Pharmacy Services Specialist - Team Lead

Pharmacy Services Specialist 2 – Team Lead

Position within Baylor Scott & White Health.

Communicates with members, providers and clients to discuss benefits of the Health Plan Pharmacy services, determines and enters prior authorizations based on criteria, resolves claims processing and eligibility issues following department policies and procedures. Works on behalf of the customer and acts as a liaison of the Health Plan to find root‑cause issues and address concerns. Serves in a lead role, acting as a subject matter expert (SME) and trainer.

• Provides oversight and reporting on performance measure goals set by the pharmacy department to comply with department and regulatory standards.
• Coaches and trains Pharmacy Services Specialist 1 staff in collaboration with the Call Center Manager; may assist with selection of new staff.
• Researches and responds to formal customer complaints within established timelines to meet regulatory requirements.
• Collects, reviews, and reports on quality control activities for all Pharmacy Services Specialist 1 staff; assists with reviewing and auditing reports as determined by management.
• Establishes and maintains excellent working relationships with key operational personnel both internally and externally.
• Guides and educates customers about fundamentals of the benefit plan to maximize value of their contract using the Health Plan website; attends client employee health benefit fairs as a Health Plan Pharmacy representative to address questions and assist members.
• Assists customers by phone or written correspondence to satisfactorily solve claims processing issues across all Health Plan lines of business, utilizing the pharmacy claims processing system and other appropriate departmental resources; performs claim tests in the system and reports findings.
• Coordinating evaluation and entry of criteria and prior authorizations with pharmacy clinical and benefits teams; documents and escalates appeals on behalf of the customer.
• Verifies and updates eligibility information on inquiries while following HIPAA standards and guidelines, including coordination of benefits (COB).
• Researches and resolves complex issues and escalated cases across multiple databases, including outreach to pharmacies to reprocess identified claims.

• Certified Pharmacy Technician (CPhT) preferred.
• Ability to lead a team and provide direction.
• Practices good phone etiquette and uses effective verbal & written communication.
• Ability to document clearly and concisely to articulate findings.
• Strong customer service skills.
• Excellent interpersonal, listening and communication skills.
• Proficiency in navigating multiple computer applications to research and address caller needs.
• Excellent analytical & problem‑solving skills and attention to detail.
• Knowledge of prescription terminology and pharmacy practices and procedures preferred.
• Ability to work independently and in a team environment.
• Ability to work in a fast‑paced environment while maintaining accuracy and performance standards.
• Must be proficient in typing and basic computer skills, particularly Microsoft Word and Excel.

• Immediate eligibility for health and welfare benefits.
• 401(k) savings plan with dollar‑for‑dollar match up to 5%.
• Tuition Reimbursement.
• PTO accrual beginning Day 1.

Note:

Benefits may vary based upon position type and/or level.

• Education:
  
  High School Diploma/GED Equivalent.
• Experience:
  
  3 Years of Experience.