Job Description

Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.

Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

  • Responsible for internal and external support functions that contribute to accurate claim processing for medications
  • Responsible for processing medication prior authorization requests from providers as well as answering incoming phone calls related to escalated issues and prior authorization request clarification

REQUIRED QUALIFICATIONS

Required Work Experience

Level 4

10 years Experience in pharmacy or medical field (eg pharmacy, health insurance, medical office, etc)

4 years Experience in Pharmacy Prior Authorization Intake & Processing

2 years Experience working on Specialty Pharmacy reviews including Medical Reviews

 Required Education

  • High-School Diploma or GED

 Required Licenses

  • Within 9 months of entry into the role, must obtain and keep current an AZ State Board Pharmacy Technician license

Required Certifications

  • Within 9 months of entry into the role, must obtain and keep current a Pharmacy Technician Certification Board (PTCB) Certification.

Preferred Work Experience

12 years Experience with a pharmacy benefit management  or prescription claim administration

10 years Experience in Prior Authorization

3 years Experience with the current BCBSAZ PBM system

2 years Experience with BCBSAZ claims software / systems Medical & Pharmacy

10 years Demonstrated experience handling confidential information

Preferred Education

  • N/A

Preferred Licenses

  • N/A

Preferred Certifications

  • Pharmacy Technician Certification

ESSENTIAL job functions AND RESPONSIBILITIES

ALL LEVELS:

  • Process Prior Authorization Reviews including intake, clarification, approvals, denials, exclusions, or another exceptions as assigned
  • Adhere to standard, urgent and exigent turnaround times for exception request & prior authorization request notifications to members & providers
  • Answer internal & external phone calls regarding prior authorization clarifications and benefit clarification escalations
  • Participate in projects that support the evolution of high value prescription benefits
  • Participates in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested.
  • Interpret and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals
  • Meet department defined production & quality metrics for Level
  • The position requires a full-time work schedule.  Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
  • Perform all other duties as assigned.

LEVEL 2 - ADDITIONAL JOB FUNCTIONS UNDER CLOSE SUPERVISION OR PEER REVIEW

  • Provide Prior Authorization recommendations to reviewing RPhs based on benefit plan design and pharmacy coverage guidelines
  • Assist in defining and improving the quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
  • Communicate recommendations in regard to medication prior authorization processing and benefit decisions.

LEVEL 3 - ADDITIONAL JOB FUNCTIONS UNDER MINIMAL SUPERVISION

  • Provide Prior Authorization recommendations to reviewing RPhs based on benefit plan design, pharmacy coverage guidelines and medical coverage guidelines
  • Setup & process all specialty medication reviews regardless of being utilized under the pharmacy or medical benefit
  • Maintain a working knowledge of all pharmacy and medical claims processing systems
  • Subject matter experts regarding prior authorization with a focus on Specialty Prior Authorization, precertification and some retrospective reviews

REQUIRED COMPETENCIES

Required Job Skills

  • Intermediate PC proficiency with word processing, spreadsheets, and claims and imaging software

Required Professional Competencies

  • Establish and maintain working relationships in a collaborative team environment
  • Flexibility in prioritization of workflow
  • Compose a variety of business correspondence

Required Leadership Experience and Competencies

  • Make use of employees' skills and abilities to deliver business objectives
  • Use available information to focus the team's activities and identify priorities

PREFERRED COMPETENCIES

Preferred Job Skills

  • Advanced PC proficiency with word processing, spreadsheets, and claims and imaging software

Preferred Professional Competencies

  • Effective interpersonal communication
  • Multicultural sensitivity
  • Claim system experience with pharmacy vendor software and/or systems

Preferred Leadership Experience and Competencies

  • N/A

Our Commitment

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank You

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.


Imagine doing life-changing work and helping more than one million Arizonans live healthier and longer lives. That’s the kind of satisfaction you’ll find when you work here. Our exceptional teams in Phoenix, Tucson, Chandler, and Flagstaff have been transforming healthcare for more than 80 years. Explore what's possible with a career at Blue Cross® BlueShield® of Arizona



Posted 7 Days Ago

Full time

R1177

Application Instructions

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