Customer Care Pharmacy Specialist
St. Luke’s Health Plan
Boise, Idaho
Full-Time | Onsite
Overview
St. Luke’s Health Plan is seeking a Customer Care Pharmacy Specialist to serve as the primary point of contact for members, prescribers, and pharmacies regarding pharmacy benefit inquiries and concerns. This role plays a critical part in delivering exceptional customer service while supporting accurate claims processing, prior authorizations, and benefit interpretation across all lines of business, including government-funded programs.
This position is full-time and onsite in Boise, Idaho.
What You’ll Do
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Serve as the first point of contact for member, prescriber, and pharmacy inquiries via phone, email, and secure messaging.
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Provide accurate, timely responses regarding pharmacy benefits, formulary coverage, claim status, and reimbursement questions.
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Review supporting clinical documentation submitted by prescribers and validate information against therapeutic indications and plan requirements.
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Process and support prior authorization requests under pharmacy benefits.
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Accurately document all member interactions in the CRM system to ensure compliance and continuity of service.
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Assist members with benefit and enrollment verification; explain plan design elements such as deductibles, copays, coinsurance, and formulary tiers.
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Resolve routine claims adjudication issues and escalate complex or clinically sensitive matters to Tier 2 or clinical teams as appropriate.
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Apply knowledge of high-cost specialty medications, pharmaceutical regulations, and cost-containment strategies.
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Maintain compliance with HIPAA, CMS guidelines, and St. Luke’s policies and procedures.
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Support continuous improvement initiatives and perform additional duties as assigned.
Minimum Qualifications
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High school diploma or GED
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Minimum of 1 year of related experience in healthcare, pharmacy, insurance, or customer service
Preferred Qualifications
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Experience in pharmacy benefit management (PBM), health plan operations, or managed care
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Familiarity with prior authorization workflows and claims adjudication processes
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Working knowledge of medical and pharmacy terminology
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Experience supporting Medicare, Medicaid, or other government-funded programs
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Strong understanding of specialty medications and formulary management
Skills & Competencies
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Exceptional customer service and communication skills
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Strong attention to detail and documentation accuracy
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Ability to interpret clinical documentation and pharmacy benefit information
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Critical thinking and problem-solving skills
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Ability to manage high-volume interactions in a structured, compliance-driven environment
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Proficiency in CRM systems and Microsoft Office applications
Working Conditions
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Primarily desk-based role
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Frequent communication with members and providers
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Frequent use of computer systems and phone systems
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Ability to remain in a stationary position for extended periods
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Occasional lifting of materials up to 25 lbs
