Pharmacy Specialist I

NJM Insurance Group

Pharmacy Specialist I managing prior authorization requests and eligibility for members at Horizon BCBSNJ. Engage with members and providers to ensure comprehensive pharmacy services compliance and effectiveness.

Posted 5/28/2026full-timeRemote • New Jersey • 🇺🇸 United StatesJuniorMid-Level💰 $44,600 - $59,745 per yearWebsite

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Pharmacy technician experienceThird party prescription program claim adjudicationClinical therapeutic interchangePrior Authorization requestsMedication Therapy ManagementFraud detectionCustomer service quality metricsRegulatory complianceMedical terminologyNational Drug Code (NDC)

Soft Skills

Interpersonal communicationProblem-solvingEfficiency improvementTeam collaborationCustomer service

Certifications & Qualifications

National Pharmacy Technician Certification (PTCB)ExCPT Certification

Industry Keywords

Managed carePharmacy Benefit Management (PBM)State of New Jersey Board of Pharmacy regulationsControlled substances regulationFormulary compliance

About the role

Key responsibilities & impact

Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues
Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design
Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination
Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied
Process complaints, appeals, grievances, executive inquiries and compliance related issues
Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary
Provide recommendations to increase efficiency, accuracy and productivity in the department
Process ad hoc request for information or reports from stakeholders
Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows
Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program
Provide support to various clinical programs within the pharmacy department

Requirements

What you’ll need

High School Diploma/GED required
Minimum of two (2) years experience as a Pharmacy technician
Minimum of two (2) years experience in third party prescription program claim adjudication preferred
Requires prior customer service/service quality initiative experience
Requires National Pharmacy Technician Certification (PTCB or ExCPT)
In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required
Knowledge of popular brand and generic drug names
Knowledge of third party prescription program claim adjudication
Working knowledge of managed care principles
Knowledge of common medical terminology
Understanding of National Drug Code (NDC)
Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement