Imagine RX Pharmacy Services Representative

Imagine360 is seeking an Imagine RX Pharmacy Services Representative to join the team! In this role, you'll serve as the first point of contact for members, providers, and pharmacies. This role delivers accurate, empathetic support on prescription benefits, refill requests, billing or order issues, formulary coverage, medication cost, prior authorization criteria, claims adjudication, and clinical program enrollment.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Serve as the primary point of contact for members, providers, and pharmacies, applying customer needs assessment and quality service standards to confer with customers and provide accurate, timely information related to RX claims processing.


• Guide and educate callers on prescription benefits, use of plan, mail order, formulary coverage, medication cost, and the status of orders, claims, or inquiries.


• Respond to inbound calls regarding benefit eligibility and prescription status inquiries, and assist network pharmacies in processing prescription claims, reviewing claims for accuracy against benefit guidelines and contract standards.


• Assist with general PA (Prior Authorization) status checks, initiate a PA by contacting the provider, and direct providers on how to start a PA.


• Answer common questions related to rejections and resolutions associated with requests.


• Ask appropriate questions and listen attentively, accurately documenting each interaction and resolution in internal systems to support continuity of care, quality assurance, compliance requirements, and operational reporting. Abide by all obligations under HIPAA related to Protected Health Information (PHI)


• Take ownership of member, provider, and pharmacy issues from initial contact through final resolution, following up timely to ensure appropriate changes were made and conferring with the Liviniti Support Team on inquiries out of your scope or that become escalated.


• Foster a team environment that values cooperation, respect, and diversity, and take on other duties and projects as assigned.

Required Experience/Education:

• High School Diploma or GED required


• Active/Current National Pharmacy Technician Certification required (PTCB or NHA)


• 1 to 3 years of experience as a pharmacy technician in a health plan, retail pharmacy, TPA, or PBM contact center setting; mail order and specialty pharmacy backgrounds are also a strong fit


• Working knowledge of pharmacy claims adjudication, benefit design, and PBM terminology


• Demonstrated ability to listen skillfully, gather relevant information, build rapport, and respond to customers in a compassionate, detail-oriented manner, with the ability to dig past a symptom to find and resolve the true root cause


• Familiarity with computer and Windows PC applications, including the ability to navigate and learn new and complex computer system applications, and comfortable multitasking and prioritizing

Preferred Experience/Education:

• Associate's or Bachelor's degree preferred, or equivalent relevant work experience

What can Imagine360 offer you?

• Multiple Health plan options


• Company paid employee premiums for disability and life insurance


• Parental Leave Policy


• 20 days PTO to start / 10 Paid Holidays


• Tuition reimbursement


• 401k Company contribution


• Company paid Short & Long term Disability plus Life Insurance


• Professional development initiatives / continuous learning opportunities


• Opportunities to participate in and support the company's diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**