Pharmacy Benefits Specialist

PURPOSE AND SCOPE:

The FreseniusRx Case Management team demonstrates a high level of case management expertise to address patient concerns and proactively plan for the maintenance of coverage.  The case manager is expected to facilitate the case management process along the healthcare continuum.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Develops professional expertise; applies company policies and procedures to resolve a variety of issues.
• Assesses patient prescription benefits and needs and develops action plans that provides for the introduction and continuation of therapy.
• Maintains comprehensive understanding of the pharmacy benefit process including but not limited to financial assistance programs, insurance plans, and payer trends at a national, state, regional, and local level.
• Assists in obtaining insurance approval and proactively plans for maintenance of coverage.
• Works with patients, healthcare providers, insurance companies, and internal operations staff to drive outcomes.
• Works on problems of moderate scope where analysis of situation or data requires a review of a variety of factors. Can identify complex issues and develop a plan accordingly related to benefit coverage.
• Builds and maintains productive working relationships with internal and external customers
• May provide assistance to junior level staff with general tasks that require a better understanding of functions, as directed by immediate supervisor.
• May refer to senior level staff for assistance with higher level problems that may arise.
• Escalates issues to supervisor/manager for resolution, as deemed necessary.
• Reviews and complies with the Code of Business Conduct and all applicable company policies and procedures, local, state and federal laws and regulations.
• Assists with various projects as assigned by direct supervisor.
• Other duties as assigned.

Additional responsibilities may include focus on one or more departments or locations.  See applicable addendum for department or location specific functions.

PHYSICAL DEMANDS AND WORKING CONDITIONS:

• The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• This position requires up to 25% travel

SUPERVISION:

• None

EDUCATION:

• Bachelor’s Degree required

EXPERIENCE AND REQUIRED SKILLS:

• 5 years’ related experience; or an advanced degree without experience; or equivalent directly related work experience.
• Healthcare, Social Work, or Nursing or a related field is a plus
• Experience in patient assistance programs, social service support, case management review preferred
• Knowledge of benefit verification and prior authorization processes
• Knowledge of private payer, Medicare and Medicaid structure and systems require
• Proficiency in CRM system
• Strong verbal and written communication skills
• Critical thinking and problem solving

Fresenius Medical Care maintains a drug-free workplace in accordance with applicable federal and state laws.