The CS Client Services Pharmacy Support Analyst are part of the front-line team at Capital BlueCross(“CBC”) and are responsible for handling all customer inquiries through multiple channels. Inquiries are received via Internet, digital communications, E-Mail, phone calls and Internal Facets Routing Queues. A complete and thorough understanding of all lines of business is required to support this initiative. Team members are also expected to provide technical, statistical, and administrative support to the supervisor and/or manager of the assigned unit.

 

The CS Client Services Pharmacy Support Analyst is responsible to conduct research and provide problem-solving support to the Brokers and Sales serving the Small, Large and Major Market Groups as well as our Individual Account plans. Technical and administrative support as well as serving as a liaison to the PBM contacts in regards to our plan benefits and policy issues. Responsible for reviewing, identifying and analyzing policies, procedures and contract issues that impact both departmental and/or Plan wide functions/operations. Prepare recommendations on all issues; root cause, action steps and monthly reports.

 

This position is responsible for providing efficient, courteous, professional quality service to Groups, Plan personnel and Brokers/Sales in a timely manner.-Ensures compliance with organizational and regulatory requirements. Topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered by Capital BlueCross Traditional, POS, PPO, HMO and Medicare Supplemental Programs. Knowledge of Medicare, PPACA, Healthy PA, CHIP, prescription, dental, vision, Chiropractic, Disease Management, Benefits Management, and other programs administered/supported by Capital BlueCross and Avalon

Researches and analyzes the customer's inquiries as related to one of our Pharmacy LOB.  Determines appropriate action by reviewing and interpreting applicable policies/procedures that are within the established regulatory requirements.  Utilizes the PC, manuals, online reference materials, Imaging, etc., to obtain benefits, enrollment and claim information.

Customer-Focus:

• Manage telephone, electronic, and face-to-face interactions professionally, efficiently and with excellent communication skills
• Effectively present and discuss the products and services to external and internal customers with integrity and understanding and accuracy with every interaction
• Focus on customer retention through first call resolution of concerns
• Establish and maintain positive relationships with customers on behalf of the company by taking personal and complete responsibility for each customer interaction
• Ensure all customers’ needs are completely met, timely, without elevation if possible
• If business needs permit, support the efforts of CBC sales representatives by conducting onsite and/or community-based educational meetings

Ensures the satisfactory resolution of routine and complex Pharmacy inquiries including, but not limited to, benefits, claim filing and processing, collection issues,  enrollment discrepancies, legal requests, Medicare Secondary Payer, and payment requests, Third Party Administrators, COBRA, reinstatements, conversions, refunds, new enrollment, transfer situations, student certifications, handicapped dependents, for all lines of business administered and supported by Capital BlueCross and Avalon. Conducts specific job related instructional sessions as requested by Supervisor.

 

Be able to prioritize work, communicate and share information with the team as necessary.

Respond to customers inquiries via telephone, correspondence, on-site, Fax, Secure IT, E-mail and personal interviews from individual customers, group administrators, providers, Capital BlueCross personnel, Host Plan personnel, attorneys, and outside entities working on the customer's behalf.

Monitors pharmacy related inquiries utilizing various system generated reports for accurate and timely resolution to ensure customer satisfaction and compliance with MTM (Member Touchpoint Measures), PPACA, ERISA, and Act 68 quality, and timeliness guidelines.

 

Provides clear and concise instructions to the appropriate Plan area, in the approved format (e.g., electronic, on-line or hard copy forms, telephone contact) for the resolution of the issues.

Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, Host Plans, Vendor contacts etc.) to obtain information and initiate necessary action.

 

Enters all information necessary to update the Facets inquiries, Sales Force Case, PBM applications, or Work Bench when appropriate, for tracking inquiry/Sales Force activity and keep notes updated on progress through resolution.  Utilizes the system to obtain background information and prevent duplication of effort.

 

Report trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, enrollment areas, benefits, policies and procedures.

 

Assists/participates with Marketing personnel and the broker community in the support of customer needs by researching and communicating information to other Company personnel or directly to the customer.  May attend or participate in marketing related activities as a representative of Capital BlueCross (e.g., open enrollment, on-site visits, etc.).

 

Performance standards, business metrics and process improvements to include:

• Complete ongoing training to stay abreast of product, service and policy changes
• Improve our quality of work on a daily basis by learning and employing new skills
• Recognize, document and alert the supervisor of trends in customer service inquiries
• Conduct yourself in a manner consistent with the values of the organization.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.