Note: The job is a remote job and is open to candidates in USA. Moda Health is an Oregon-founded healthcare company focused on providing quality health coverage, compassionate member support, and community health services. The Pharmacy Customer Service Representative I supports members, agents, providers, pharmacies, and other stakeholders by answering pharmacy benefit, eligibility, claims, and coverage questions. The role also resolves complaints and appeals, processes claim adjustments, provides follow-up, and handles escalated issues while maintaining service standards.
Responsibilities
- Responds to questions and assists customers via telephone, virtual meeting platform or in person regarding their claim benefit questions from callers on both group and individual pharmacy products. Provide solutions to problems, confirm eligibility, explain benefits and/or plan coverage
- Repeatedly analyzes situations, communicates effectively, and provides accurate information in a fast-paced environment that includes dealing with escalated situations and upset people
- Applies mathematical skills to provide and determine correct benefit information
- Reviews, updates, and becomes familiar with new and revised benefit information, regulations, benefit information and claim processing procedures
- Be familiar with drug names and recognize new drugs as they are released and added to the Moda drug list
- Requests claim adjustments required because of error or new information
- Resolves and record complaints, appeals, and inquiries
- Contacts physicians, pharmacies and PBM’s when necessary to answer questions and obtain or provide information
- Works with a culturally diverse population that can vary in age
- Provides timely follow up and return calls when required
- Maintains departmental service standards related to phone calls
- Continues education and training through on-the-job communication with Supervisors and/or tenured Customer Representatives and by attending trainings scheduled by leadership
- Consults with Leadership on problem cases and interfaces with interdepartmental personnel in resolving escalation questions
- Ability to maintain agreed upon work schedule and regularly work agreed upon shifts
- Performs other duties as assigned
Skills
- High school education or equivalent experience
- 1-2 years in a fast-paced customer service environment
- Type a minimum of 25-wpm on a computer keyboard
- Ability to apply mathematical skills to provide and determine correct benefit information
- Proficient with Microsoft Office Applications, including Word and Excel and Outlook
- Strong verbal, written, and interpersonal communication skills
- Ability to interact professionally, patiently, and courteously with customers over the phone, in virtual meeting platforms and in person
- Proficiency in working thoughtfully and appropriately with a culturally, linguistically and ability diverse population
- Ability to work well under pressure; work with frequent interruptions, shifting priorities and quickly adapt to change
- Ability to work independently and as part of a team
- Ability to anticipate, meet and/or exceed customer needs and expectations in a professional manner
- Ability to come to work on time and on daily basis
- Maintain confidentiality and project a professional business image
- Ability to meet or exceed department standards and deadlines
- Ability to multitask and efficiently utilize multiple (7-8) computer programs and packages at the same time
- A pharmacy or insurance setting preferred
Benefits
- This is a FT WFH position
- 401(k) matching
- Dental insurance
- Health insurance
- Vision insurance
Company Overview