Clinical Pharmacy Specialist

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.

• Schedule: Monday-Friday 8AM-6PM EST, must be available to work nights and weekends on a rotating basis

• →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

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

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:

BCBST's EEO Policies/Notices