Pharmacy Benefit Specialist-2--------------------------------------------------------------- This position is responsible for working with CareOregon members, their providers, and pharmacies to support the pharmacy benefit and prescription needs under the major medical benefit. Core responsibilities include customer service and claims processing, as well as assistance with prior authorizations, formulary exceptions, appeals, grievances, and projects. Estimated Hiring Range: $20.51 - $25.06 Bonus Target: Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. --------------------------------------------------------------- Essential Responsibilities Customer Service and Claims Processing - Communicate in a professional and respectful manner. - Maintain confidentiality within HIPAA regulations and function on “need to know” principles. - Respond to drug coverage inquires in an accurate and timely manner to members, members’ representatives, providers, and CareOregon staff. - Educate members, providers, pharmacies, and CareOregon staff about the CareOregon formularies and pharmacy benefit policies. - Document all customer service activities according to organization requirements. - Follow policies and procedures to answer questions from members, providers and CareOregon staff regarding claims processing as it pertains to the CareOregon pharmacy benefits and coverage of drugs under the major medical benefit. - Follow policies and procedures to determine a resolution to pharmacy claims adjudication issues or triage to other CareOregon staff for assistance. Data Entry and Clerical Support - Sort incoming faxes and distribute according to assignments. - Maintain files according to unit protocols. - Perform data entry into the claims processing system, document management systems, databases and spreadsheets as assigned. - Clerical Assistance for pharmacy projects, including, but not limited to distribution of education materials to members, providers or pharmacies, letters & mailings, and reports. Prior Authorizations (PA) and Formulary Exceptions - Verify member’s plan eligibility and applicable benefit for drug coverage. - Review member’s medication and eligibility history, load authorization in claim adjudication platform(s). - Assist members and providers with the PA, formulary exception and coverage determination process. - Follow policy & procedures to facilitate a resolution for prior authorization, formulary exception and coverage determinations requests. Notify members, providers or providers staff of prior authorization and formulary exception decisions. Appeals and Grievances - Explain pharmacy appeal and grievances provisions and process to members, providers and CareOregon staff. - Assist PBS II and PBS Lead with setting up pharmacy benefit appeals and grievances. Project Coordination - Minimal project participation. Experience and/or Education Required - Minimum 1 year work experience on a pharmacy team (i.e., retail, long-term care, or hospital) or 1 year experience in a health insurance plan Preferred: - Pharmacy Technician experience Knowledge, Skills and Abilities Required Knowledge - General understanding of managed care, Medicare, and Oregon Health Plan concepts Skills and Abilities - Proficient with Microsoft Office Products and general computer literacy - Familiarity with medical and pharmaceutical terminology - Ability to learn and effectively navigate CareOregon and PBM software programs necessary to perform job responsibilities - Ability to follow policies and procedures in performing job responsibilities - Effective listening, verbal, and written communication skills - Ability to exercise professionalism - Growing ability to network and utilize internal and external resources - Ability to focus on and comprehend information - Ability to learn new skills and abilities - Ability to assess a situation and use critical thinking skills and company resources to determine a solution - Ability to accept managerial direction and feedback - Ability to tolerate and manage stress - Results and service oriented - Ability to be flexible and adaptable - Ability to organize, plan, and prioritize daily workflow within time constraints - Ability to work in an environment with diverse individuals and groups - Ability to learn, focus, understand, and evaluate information and determine appropriate actions - Ability to accept direction and feedback, as well as tolerate and manage stress - Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day - Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☐ No ☒ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information. We are an equal opportunity employer CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.

Job Description: Summary: This position supports the Utilization Management (UM) workflows by providing administrative support and customer service. This position acts as a resource for both internal and external customers through completing timely and accurate inbound and/or outbound calls, creating authorizations via phone, Care Advance Provider Tool, and fax for inpatient and outpatient procedures, behavioral health, and durable medical equipment. Essential Accountabilities: Level I - Facilitates inbound and outbound calls to customers (members and providers) by delivering excellent customer-centered service providing information regarding services in a call center environment. - Responds to customers in a professional, efficient manner to encourage public acceptance of products, services, and policies. - Perform triage for UM Services. - Serves as the primary contact for providers regarding authorization requests. - Contacts members and providers concerning regulatory requirements relating to Department of Health (DOH) notifications and other regulatory requirements such as the National Committee for Quality Assurance (NCQA) guidelines. - Provides timely response to all research inquiries from other departments and assures the response is thorough, accurate, and within regulatory timeframes. - Processes fax requests from the designated fax and system queues. - Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. - Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. - Regular and reliable attendance is expected and required. - Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) - Assists and performs tasks associated with project and departmental management. - Backup Team Leads by assisting with questions when needed. - Work on assigned offline projects. - Provides, prepares, and assists with preliminary support to multiple levels of providers and or members (as well as others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers, members, pharmacies, pharmacists, and support staff. - Provide one-on-one support, coaching, and training to UM Services Reps. - Collaborates with other key departments (Claims, Customer Service, related care management units) to ensure end-to-end process for authorizations, telephonic notifications, and/or care management referrals is accurate and complete. Level III (in addition to Level II Accountabilities) - Assists Team Leads with assigned tasks when necessary (including but not limited to authorizations, claims, care management referrals, monitoring and controlling inventory levels/call queues, timeliness, reporting). - Meet departmental requirements for Facets UM Services workflows and PEGA. - Resolves escalated customer questions and complex concerns. - Assists Medical Directors with scheduling Fair Hearings. - Assists with coordinating Grievance and Appeals requests. - Assist with all Blue Card Claims escalations. - Assist management with the review and creation of desk level procedures, acting as a subject matter expert for UM Services. Minimum Qualifications: NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels - High School Diploma or GED. - Experience with using a desktop computer in a professional environment, preferably with Microsoft Office Products. - Call center experience preferred, not required. - Strong analytical and problem-solving skills. - Strong written and verbal communication skills and ability to work within a team. - Demonstrated organizational skills to manage multiple projects and priorities. - Self-motivated and able to work independently, as well as on intra- and inter-departmental teams where needed. Level II (in addition to Level I Qualifications) - 2 years’ experience working with managed care or healthcare industry. - Ability to apply in-depth knowledge of complex rules, such as those of the authorization process, regulatory processes/time frames, care management systems and processes, departmental policies and procedures, product lines, and contract benefits. - Advanced skills working between multiple programs and applications simultaneously. - Demonstrates willingness to develop collaborative solutions to achieve a better end-to-end process. - Demonstrates proficiency in basic navigation and utilization of department specific applications. - Demonstrates role-specific competencies as it pertains to their work unit on a consistent basis. - Active demonstration of broad knowledge base and positive work habits as evidenced by ability to train new staff, take on new challenges, flexibility in work assignments, and participation in meetings and projects as assigned. Level III (in addition to Level II Qualifications) - 4 years’ experience working with managed care or healthcare industry. - Demonstrates a thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures to identify eligibility and coverage and assisting other staff and other areas within the company with related inquiries. - Demonstrates operational knowledge of FACETS application and workflow processes - Ability to resolve/respond to customer inquiries across multiple plans with limited assistance. - Ability to collaborate within the organization when issues arise with limited assistance. - Ability to identify potential systemic issues and report as necessary without supervisor assistance. Physical Requirements: - Ability to work prolonged periods sitting at a workstation and working on a computer. - Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time. - Ability to work in a home office for continuous periods of time for business continuity. - Ability to travel across the Health Plan service region for meetings and/or trainings as needed. - Manual dexterity including fine finger motion required. - Repetitive motion required. - The ability to hear, understand and speak clearly while using a phone, with or without a headset. ************ In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation Range(s): Level I - Min 18.55 Mid 22.72 Max 26.90 Level II - Min 19.22 Mid 24.99 Max 30.76 Level III - Min 20.02 Mid 26.52 Max 33.03 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. Act as a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators. • Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal. • Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work. • Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures. • Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. • Can review a clinical determination and understand rationale for decision. • Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process. • Serves as point person for newer staff in answering questions associated with claims/customer service systems and products. Educates team mates as well as other areas on all components within member or provider/practitioner complaints/appeals for all products and services. • Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise. • Identifies trends and emerging issues and reports on and gives input on potential solutions. • Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required. • Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned. Required Qualifications: - 1 year experience in reading or researching benefit language in SPDs or COCs - Demonstrated ability to handle multiple assignments competently, accurately and efficiently. - Excellent verbal and written communication skills. - Computer navigation ability and ability to multitask. - Excellent customer service skills. - Strong Leadership skills - Experience documenting workflows and reengineering efforts. Preferred Qualifications: - 1 year of experience in research and analysis of claim processing. - 1-2 years Medicare part C Appeals experience. - Project management skills are preferred. - Strong knowledge of all case types including all specialty case types Education: - High School Diploma Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $35.29 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/24/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Role Description The Forfeiture Specialist is responsible for data entry of bail forfeitures, judgments, court communications, court notices etc. into our electronic database and the continual management of bail forfeitures/judgments by communicating with our agent force and/or the courts and updating our databases accordingly. - Accurately and timely enter bail forfeiture/judgment data and documents into the electronic database, for states or regions assigned by management. - Manage, follow up and update bail forfeitures/judgments for the states assigned by management in the electronic databases by contacting and communicating with the agent force via phone calls and emails. - When applicable, utilize the online court websites to obtain additional updates, status’ and discharges of bail forfeitures/judgments. - Work with the Bail Account Management and Bail Accounting teams, to ensure proper and timely payment of forfeitures/judgments and/or court costs. - Process bail exonerations. - Answer company phone when needed. - Other related duties as assigned by management. Qualifications - High school diploma or equivalent required, associate’s degree preferred. - Strong knowledge of Microsoft Office program. - Excellent customer service and time management skills. - Ability to prioritize tasks assigned to meet deadlines. - Ability to multi-task. - Strong written and verbal communication skills. - Ability to learn and use new operational systems. Benefits - Competitive compensation package. - Generous 401K employer match. - Employee Stock Purchase plan with employer matching. - Generous Paid Time Off. - Excellent benefits that go beyond health, dental & vision, focused on your whole family’s wellness, including your physical, mental and financial wellbeing. - A core C&F tenet is owning your career development, providing a wealth of ways for you to keep learning, including tuition reimbursement, industry-related certifications and professional training. - A dynamic, ambitious, fun and exciting work environment. - Encouragement of social and community responsibility, matching donation program, volunteer opportunities, and an employee-driven corporate giving program. Company Description Crum & Forster (C&F), with a proud history dating to 1822, provides specialty and standard commercial lines insurance products through our admitted and surplus lines insurance companies. C&F enjoys a financial strength rating of "A+" (Superior) by AM Best and is proud of our superior customer service platform. Our claims and risk engineering services are recognized as among the best in the industry. - More than 2000 employees in locations throughout the United States. - Recognized as a great place to work, earning several workplace and wellness awards, including the 2025 Great Place to Work® Award. - Part of Fairfax Financial Holdings, a global, billion dollar organization.