PSS - Claims & Authorization Specialist

Description

PSS - Care Coordination Specialist

Position Type: Full-Time, In-Office (Nashville)

Department: Pharmacy Operations & Product Support Team

Reports To: Pharmacy Support Specialist Supervisor

Position Summary

The PSS Care Coordination Specialist is the front-line ambassador for our pharmacy team. This role focuses heavily on delivering a high level of service by handling high-volume inbound communications from members and healthcare providers. This role will be responsible for triaging incoming inquiries, managing administrative tasks, and ensuring all front-line interactions are resolved, logged, and routed accurately.

Core Responsibilities

• •Front-Line Customer Service: Answer and manage inbound calls from members and providers, consistently delivering a high level of professional service.
• •Call Triage & Routing: Efficiently triage complex clinical or technical inquiries, routing them to the appropriate clinical or advanced operations teams.
• •Concern Resolution: Resolve and meticulously log standard member or provider concerns in the internal tracking system.
• •Administrative Support: Complete foundational administrative tasks related to incoming prior authorizations and appeals (e.g., document sorting, data entry, case routing).
• •Outbound Outreach: Support the clinical pharmacy team by making routine outbound informational calls to members and providers.
• •Operational Flexibility: Perform additional basic operational projects and tasks as needed by the management team.

Requirements & Qualifications

• •Education: High school diploma or equivalent
• •Experience: Proven experience working in a call center or high-volume phone customer service environment is required.
• •Communication: Excellent verbal and written communication skills are a must.
• •Healthcare Knowledge: Experience in Pharmacy Benefit Management (PBM) operations or the general healthcare industry is preferred but not required .
• •Technical Comfort & CRM Navigation: Highly comfortable adapting to new digital tools and navigating multi-screen workflows, including Customer Relationship Management (CRM) modules, ticketing platforms, and basic database software to accurately log and route customer interactions.
• •Technical Skills: Proficiency in Google Work products (Docs, Drive, Slides) and Microsoft Office (Word, PowerPoint, Excel).
• •Mindset: Fast learner with a strong interest in potential growth opportunities as product roles expand.

Requirements

Qualifications and skills:

• •Competitive candidates will have a minimum of 2 years experience in PBM operations, including medical necessity or prior authorization case reviews
• •Candidates without PBM experience will be considered if they have leadership experience, e.g. team lead or trainer, or experience with special projects, e.g. inventory management
• •Fast learner and interested in potential growth opportunities as the product roles expand
• •Excellent verbal and written communication skills a must
• •Pharmacy technician experience preferred
• •PBM experience preferred
• •A track record of fostering collaboration, resolving conflicts, and managing projects is preferred.
• •Excellent technical skills in Google Work products (Docs, Drive, Slides) and Microsoft (Word, PPT, Excel)

Company Standard Requirements:

• •Ability to work well with others in a collaborative environment
• •Ability to get things done with resources you don’t control
• •Willingness to admit you don’t know and ask for help
• •Exhibit constant curiosity and a drive to problem solve
• •Exhibit desire to learn and grow on a continuous basis