Utah Retirement Systems

Pharmacy Claims Specialist

Location UT-Salt Lake City
Posted Date 2 weeks ago(9/23/2022 4:43 PM)
Job ID
Minimum Starting Wage
USD $18.32/Hr.

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis.   As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare.   We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

Job Description

Plays a critical role in the PEHP’s efforts to serve and create value for our member by performing pharmacy technical and customer service support, through inbound and outbound communications, ensures proper claims adjudication through prior authorizations, education (members, providers and pharmacies), and member advocacy.  Other duties include assisting the pharmacy department in drug pre-authorization evaluation, the disputed/appealed pre authorization process, group setup, and benefit verification for all PEHP members. Preference will be given to individuals with previous pharmacy experience. Successful performance for this position requires a genuine interest in helping others, the ability to transition between multiple task rapidly, the ability to learn and share complex information about PEHP pharmacy benefits, and a high level of commitment and dependability.



  1. Receives and responds to incoming phone calls from policy holders, claimants, providers, pharmacies and representatives of other insurance companies.  Responds to complex questions regarding medical and pharmacy claims processing, policy descriptions and interpretations, payment processes, coordination of benefits, eligibility for covered services and enrollment questions.
  2. Educates members, providers and pharmacies through outbound phone calls providing alternatives to formulary and non-covered medications.
  3. Provides information on co-pay assistance programs offered through pharmaceutical manufacturers.
  4. Resolves pharmacy issues pertaining to pre-authorizations, disputes, eligibility, mail-order, benefits interpretation and claims payments.
  5. Evaluates and determines coverage on prior authorization requests for drugs on the pharmacy or medical benefit and select durable medical equipment (DME).
  6. Prepares and collects clinical information for disputes and appeals.
  7. Communicates pre-authorization and disputed prior authorization approvals and denials with physicians, members, PEHP Customer Service, PEHP Case Management, and the PEHP Benefits Review Department through mailings, inbound/outbound phone calls, and appropriate usage of the PEHP Message Center.
  8. Assists the Pharmacy Supervisor in overseeing pharmacy related information presented on the Intranet. 
  9. Maintains and reconciles Medicare D electronic eligibility files.
  10. Assists in formulary management mailings. 
  11. Reimburses PEHP members that have exceeded their deductible or maximum out of pocket on their High Deductible Health Plan.
  12. Processes Coordination of Benefits through the PBM system.
  13. Maintains strict confidentiality.
  14. Performs other related duties when assigned.

Required Experience

Education and Experience

High School diploma and completion of post high school courses in pharmacy technician training; plus two (2) years of pharmacy or customer service work experience; or an equivalent combination of education and experience.


Certified Professional Coder (CPC) certification and or specific experience in claims processing, pharmacy software applications, and electronic billing procedures is preferred.


Licensure as a registered pharmacy technician in the State of Utah preferred.


Knowledge, Skills, and Abilities

Requires a working knowledge of Pharmacy software programs and electronic billing procedures; demonstrated competency using the internet; proficiency with various office management systems related to alpha and numeric record keeping; interpersonal communication skills; and telephone etiquette.  Must have a working knowledge of personal computer operations (PC/MS DOS) such as Word and Excel; 10 key operation; training methods; and public relations skills.


Must have the ability to apply intermediate  mathematics related to the metric system to calculate drug dosages as related to pharmacy/medical claims; pharmacy adjudication policies; intricacies related to drug usage, dosage, and drug definitions and codes;   analyze a variety of  escalated  issues and problems and make recommendations directly related to pharmacy claim functions; communicate effectively verbally and in writing; ability to follow written and verbal instructions; establish and maintain effective working relationships with professionals, executives (public and private) department heads, co workers and the public; follow directions accurately and be capable of following a well organized work routine; work independently and deal effectively with stress caused by work load and time deadlines.



Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions. 


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