RemoteMust work Eastern Time hours (8 AM–6 PM) and rotating nights and weekends.
About the job
Requirements
High school diploma or equivalent.
Two years of pharmacy experience.
National Certification as a Pharmacy Technician (PTCB).
Proficiency in Microsoft Office, including Outlook, Word, Excel, and PowerPoint.
Ability to organize work and handle multiple projects.
Oral and written communication skills.
Interpersonal and organizational skills.
Decision-making and problem-solving skills.
Ability to work independently with minimal supervision.
Knowledge of medical and pharmacy terminology.
Responsibilities
Enter authorizations and test claims into the pharmacy benefit system to support appropriate claim adjudication.
Handle incoming and outgoing calls from providers, members, and members’ representatives to assist with coverage determinations and appeals.
Monitor and respond to emails and FACETs inquiries from internal customers about pharmacy reviews, appeals, claims issues, and related matters.
Review daily pharmacy reports to ensure appropriate claims processing.
Assist with departmental audits and quality improvement activities.
Work evenings, holidays, and weekends, including on-call rotations, as needed to ensure adequate business coverage.
Desired Qualifications
Experience in Medicare, Medicaid, retail pharmacy, or managed care settings.
Experience with coverage review processes.
We are hiring a Clinical Pharmacy Specialist at BCBST!
In this role, you will support Medicare and D-SNP coverage review activities, helping ensure members receive timely and appropriate access to pharmacy benefits and services. You’ll work closely with pharmacists and healthcare providers to build and manage cases, contributing to important coverage determinations that directly impact member care and health outcomes.
You will contribute to team success by balancing independent work with collaboration across the pharmacy team. This role offers the opportunity to develop specialized knowledge in coverage review while serving as a key resource in the review process. You’ll engage with providers, manage multiple priorities, and play an important part in delivering high-quality service to both members and providers.
To be successful in this position, you’ll bring strong computer and organizational skills, attention to detail, and the ability to navigate complex information in a remote environment. Ideal candidates will have experience in Medicare, Medicaid, retail pharmacy, or managed care settings. Previous experience with coverage review processes will help support a smoother transition into the role.
We foster a culture where innovation is encouraged, supporting employees with the tools and resources needed to succeed while promoting growth, creativity, and continuous learning.
Note:
Schedule: Monday-Friday 8AM-6PM EST, must be available to work nights and weekends on a rotating basis
Job Responsibilities
Enter authorizations and test claims into the pharmacy benefit system to ensure appropriate claim adjudication.
Handle incoming and outgoing phone calls from providers and/or members/members representatives to assist in completing coverage determinations and appeals.
Monitor and answer emails and FACETs inquiries from internal customers regarding pharmacy reviews, appeals, claims issues, etc.
Review daily pharmacy reports to ensure appropriate claims processing.
Assist with departmental audits and quality improvement activities.
May be required to work evenings, holidays and weekends to ensure adequate coverage to meet the business needs including on call rotations
Job Qualifications
Education
High School Diploma or equivalent
Experience
2 years - Pharmacy experience required
Skills\Certifications
National Certification as Pharmacy Technician (PTCB)
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be a team player, be organized and have the ability to handle multiple projects
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Proven decision making and problem solving skills
Ability to work independently and with minimal supervision
Knowledge in Medical/Pharmacy terminology
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Applying for this job indicates your acknowledgement and understanding of the following statements:
BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.
Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.