Location: Remote

About Capital Rx

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Responsibilities:

• Triage, investigate and resolve escalated clinical phone calls and cases from members, pharmacies, and providers
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turn around times
• Perform peer-to-peer reviews with providers when requested
• Provide detailed and thorough documentation in prior authorization cases, overrides and call center cases
• Provide support for clinical programs as needed, including conducting outreach calls to prescribers and members to obtain clinical information
• Ensure customer satisfaction, demonstrate genuine compassion and care, optimize the customer experience and provide professional customer support and service
• Effectively ask probing questions to identify and resolve multiple issues and address concerns effectively, efficiently, and in a timely manner
• Effectively communicate issues and resolutions to members, pharmacies, providers, and appropriate internal stakeholders
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies
• Support the Fraud, Waste, and Abuse program by reviewing pharmacy claims information and communicating findings to appropriate internal staff
• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frame
• Support staff training and development as required
• Work collaboratively with internal business and clinical partners to support initiatives including clinical interventions, data and claims review, and on-boarding of new clients, as required

Required Qualifications:

• Active, unrestricted, pharmacist license
• Bachelors or Doctor of Pharmacy Degree with 2+ years of pharmacy practice experience
• 1+ years of Medicare PBM experience
• Experience in customer service, call center and prior authorization preferred
• Excellent communication, writing, and organizational skills
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven call center environment
• Self-motivated and detail-oriented problem solver
• Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team
• Have a designated workspace (an office, spare bedroom, etc) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
• Have the following internet connectivity: DSL, cable modem or fiber with a wired connection to device (wi-fi not allowed). Internet speed of one gigabyte (940bps) is required

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.