Provider Relations Representative

Job Title: Provider Relations Representative

Reports to: Manager, Provider Relations

Location: Remote

FLSA Status: Non-Exempt

Job Summary

Within the Pharmacy Services Department, the Provider Relations Representative is responsible for providing support to pharmacy members seeking assistance or information regarding: contracted PBMs and health plans, payment rates and reimbursement status, claims processing and reconciliation, and all AlignRx programs and services. The position utilizes tools, resources, and guides to provide prompt and accurate addressing of questions and resolution of issues. The Provider Relations Representative often works closely with the PBM Account Executive and Senior PBM Account Executive on PBM and health plan issues.

Essential Job Functions

  • Serve as the front-line contact for AlignRx pharmacy members requesting information on, assistance with, or explanation of claims processing issues, AlignRx PSAO contracts, pharmacy not-contracted, direct contracting, claims pricing, claims reconciliation, and missing data, etc. (requests received via pharmacy member service calls, emails, or faxes).
  • Maintain knowledge of existing and newly launched AlignRx programs and services, including mastering content of AlignRx programs and services guides for the purpose of servicing pharmacy members.
  • Conduct data pulls to validate contract information.
  • Follow up on eRecon and Central Pay issues for pharmacy members.
  • Follow defined work plans and leadership direction to meet due dates when addressing pharmacy member concerns or adverse issues.
  • Abide by department workflow, policies, and procedures.
  • Remain current on pharmacy industry trends and aware of AlignRx pharmacy member business needs and concerns.
    Monitor and address issues from Customer Support email box.
  • Document call and work activity in the Pharmacy Data Management System (PDMS) and review Daily Notes report to ensure follow-up and resolution.
  • Attend and actively participate in Provider Relations team meetings.
  • Provide support to other team members, as needed.

Minimum Qualifications

  • Bachelor’s degree in a business-related field preferred.
  • Two to three years as a pharmacy technician in a retail pharmacy environment.

Additional Responsibilities

  • Perform other duties or projects as assigned by senior management.

Knowledge, Skills & Abilities

  • Excellent verbal and written communication skills.
  • Good interpersonal skills: able to work and communicate effectively with all levels of co-workers, clients, and other external contacts.
  • Strong organizational and time management skills.
  • Dependable with good attendance and adherence to timelines and schedules.
  • Strong analytical skills.
  • Good problem-solving skills.
  • Consistent follow-through on issue resolution.
  • Resourceful, with the ability to take initiative in development and completion of projects.
  • Strong sense of customer service.
  • Basic computer knowledge through effective use of a personal computer including Microsoft Office applications, specifically: file management skills, Internet, Microsoft Windows, database, word processing (Word), spreadsheets (Excel), presentation software (PowerPoint), graphics.
  • Knowledge of and experience in the pharmacy and healthcare industry regarding terminology and retail pharmacy operations, including understanding of how and why pharmacy claims process (e.g., calculation of copayments, pricing hierarchies).
  • Basic drug knowledge and understanding of Therapeutic Categories (TC), Multi-Source Indicators (MSI), Generic Product Identifier (GPI), Generic Code Number (GCN), Drug/claim statuses: Paid vs. Captured; PDL/NPDL; “F” – Formulary (paid) vs. “G” – Non-formulary paid.

Physical Requirements/Working Conditions

  • Sedentary work, requiring the following physical activities: sitting for long periods of time; occasional bending, squatting, kneeling, stooping; good finger dexterity and feeling; frequent repetitive motions; talking, hearing, and visual acuity.
  • Lifting of up to 20 pounds of paper supplies or minor office equipment.
  • Conducting work in a business-type environment (e.g., desk, table) that can facilitate the use of two computer monitors.

NOTE: The above statements are intended to describe the general nature and level of work performed by an employee in this position. These statements are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees in this position.

AlignRx is an equal opportunity employer and is committed to providing a workplace free from harassment and discrimination. We celebrate unique differences of our employees, knowing diversity drives innovation and the success of our business. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, gender identity or expression, age, marital status, veteran status, disability status, pregnancy, parental status, genetic information, political affiliation, or any other status protected by applicable laws or regulations.

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Provider Relations Representative