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.

For most jobs, remote work is available for 9 out of every 10 workdays.

POSITION SUMMARY

The Pharmacy Clinical Services Supervisor plays a vital leadership role in PEHP’s mission to serve members through trust, commitment, value, innovation, and excellence. This position supports PEHP’s efforts to optimize pharmacy cost‑saving initiatives while ensuring that members and providers are treated with respect and are given accurate information and advice. The Supervisor performs a variety of complex first‑line supervisory duties related to planning, organizing, directing, and controlling the day‑to‑day functions of the Pharmacy Clinical Services team. Responsibilities include coordinating daily workflows, monitoring calls, and resolving high‑level issues related to pharmacy customer service, pre‑authorization processes, and pharmacy benefit interpretation. Successful performance requires a thorough understanding of PEHP pharmacy benefits and preauthorization requirements, a strong desire to serve others, excellent judgment, and superior management, organizational, communication, and conflict‑resolution skills.

ESSENTIAL JOB FUNCTIONS AND DUTIES

1. Makes recommendations in evaluating worker performance, job retention, advancement, discipline and discharge. Participates in recruitment and selection process for new hires.
2. Acts as a member advocate to proactively resolve insurance issues involving pharmacy claims, pharmacy enrollment, pharmacy benefit interpretation, pharmacy preauthorization, and coordination of benefits (COB).
3. Ensures all team deadlines and responsibilities are met. Develops team members to maximize potential, helps team members meet goals, welcomes newcomers, and promotes a team atmosphere.
4. Supervises training, sets employee goals, coaches, delegates assignments, coordinates special training, maintains quality control, and sets goals and priorities in a timely and efficient manner.
5. Supervises the daily operations and activities of the Pharmacy Clinical Services team, ensuring efficient workflow and timely completion of all responsibilities.
6. Communicates pharmacy benefits, prior authorization, and appeal decisions effectively verbally and in writing.
7. Serves as the designated backup to the Pharmacy Clinical Services Specialists and assumes responsibilities as needed during low staffing or peak workload periods, including handing pharmacy phone calls, reviewing prior authorizations, managing pharmacy workbaskets, and performing other daily operational duties.
8. Coordinates with the Pharmacy Program Supervisor to communicate newly or terminated benefits (such as formulary or tier changes, program changes, etc.) to the Pharmacy Clinical Services team and other departments when applicable.
9. Identifies and resolves complex non-clinical issues and serves as a liaison to streamline communication between Pharmacy Clinical Services team and the pharmacy leadership team, ensuring matters are addressed through established channels and minimizing unnecessary escalations.
10. Oversees the processing of COB claims by using the claims payment system from the contracted Pharmacy Benefit Management (PBM) system.
11. Maintains daily, weekly, monthly and quarterly reports that track productivity for the Pharmacy Clinical Specialists, including preauthorization and appeal count, call volume, quality assurance audits, and daily work activities.
12. Assists in auditing randomly selected phone calls and preauthorization to evaluate Pharmacy Clinical Specialists for customer service competencies (including empathy, professionalism, and communication quality), as well as overall performance and accuracy.
13. Recommends and implements procedures under the direction of the Member and Provider Services Director.
14. Serves URS Retirement and PEHP employees in addressing pharmacy claims adjudication issues, answering questions regarding pharmacy benefits, pharmacy preauthorizations, pharmacy appeals, and pharmacy claims status.
15. Maintains regular and reliable attendance.
16. Maintains strict confidentiality.
17. Performs other related duties as assigned.

MINIMUM QUALIFICATIONS

Education and Experience

High School diploma and four (4) years of progressively responsible experience performing pharmacy administrative and technical duties; or an equivalent combination of education and experience. Current licensure as a Certified Pharmacy Technician in the State of Utah is required.

Certification Professional Coder (CPC) certification, specific experience in claims processing, pharmacy software application, electronic billing procedures, and PEHP experience is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Various office management systems related to alpha and numeric record keeping.
• Healthcare Information Systems.
• Pharmacy software programs.
• Electronic billing procedures.
• Personal computer operations.
• Microsoft Office Suite.
• 10-key.

Required advanced knowledge of:

• Medical, dental, pharmaceutical and Medicare Supplement claims adjudication policies, procedures, and processes.
• Customer service techniques; adjudication, policies, procedures and processes.
• Intricacies related to medical, dental, pharmaceutical, and mental health claims.
• Claims review processes and procedures.
• Healthcare coding.
• Enrollment processes.
• Basic medical terminology.
• Pharmacy adjudication policies.
• Intricacies related to drug usage, dosage, definitions, and codes.

Required mathematical skills include working knowledge of:

• Apply intermediate mathematics related to the metric system to calculate drug dosages as related to pharmacy/medical claims.

Must possess excellent communication skills:

• Telephone etiquette.
• Public relations skills.
• interpersonal communication.
• Negotiation techniques.
• Communicate effectively verbally and in writing.
• Establish and maintain effective working relationships with professionals, executives, department heads, coworkers, and the public.
• Analyze a variety of escalated issues and problems and make recommendations directly related to pharmacy claim functions.

Must have the ability to:

• Multi-task by handling a variety of duties in a timely and efficient manner.
• Draft technical reports, documents, manuals, and instructions.
• Document information accurately and succinctly.
• Supervise and motivate.
• Maintain effective working relationships with professionals, department heads, co-workers, and the public.
• Provide training for co-workers.
• Follow written and verbal instructions.
• Follow a well-organized work routine.
• Deal effectively with stress caused by workload and time deadlines and handling difficult or irate phone calls.
• Work well in a team environment as well as independently.
• Prioritize work.
• Perform within deadlines.
• Follow through with assignments.
• Follow written and verbal instructions.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Work Environment

Incumbent performs in a typical hybrid (office/home) work environment 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, and finger dexterity are required to perform essential functions.