L.A. Care Health Plan CSC A&G Pharmacy Specialist in Los Angeles, California

DUTIES The Grievances & Appeals Pharmacy Specialist (G&A; Pharmacy Specialist) will receive, investigate and resolve member complaints and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with CMS, DHCS, DMHC, NCQA regulatory requirements. The position reviews pre-service authorizations, concurrent and post-service (retroactive review) medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes. Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines. Responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.


*EDUCATION * Required High school diploma required

Preferred Associates Degree

*LICENSES/CERTIFICATIONS * Preferred Pharmacy Technician

*EXPERIENCE * Required 1 to 3 years experience in Managed Care with specific experience in resolving member or provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns. Experience working with firm deadlines, able to interpret and apply regulations. Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills. A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies. Proficient in MS Office applications, Word, Excel and Power Point.

Preferred: 5 years experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. Knowledge of Medical terminology and strong advocacy experience. Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese, Korean

Job Title: CSC A&G; Pharmacy Specialist

Job Category: Administrative & Business Professionals

Department: Customer Service Center Appeals & Grievance

Location: Headquarters, Downtown Los Angeles

Position Type: Full-time

Position Control Number: 1122

Pay Grade: H