JEKIEREA NILES

Prime Therapeutics is a pharmacy benefit manager

(PBM) that focuses on connecting health care and

drug coverage. Job descriptions vary widely—from

remote Clinical Pharmacy Technicians to Physician

Clinical Reviewers and Member Services

Specialists—but core expectations center on

customer empathy and navigating health plans.

Typical Duties

1. Clinical & Pharmacy roles

• Clinical Pharmacy Technician Sr: Evaluates and authorizes prior authorization pharmacy requests. Communicates with doctors' offices regarding clinical criteria, benefit coverage, and formulary alternatives.
• Physician Clinical Reviewer: Conducts timely medical reviews for service requests that do not initially meet medical necessity guidelines.

2. Member & Customer Support

• Member Services Specialist: Manages incoming calls and emails from members, pharmacies, and doctor offices. Investigates and resolves benefit inquiries while strictly adhering to HIPAA privacy standards.
• Process Prescriptions: Review and enter electronic prescription data into digital dispensing systems.
• Verify Insurance: Manage benefits investigations, prior authorizations, and claims troubleshooting.
• Liaise with Providers: Contact prescribers to resolve prescription issues, refill requests, or claim denials.
• Handle Patient Calls: Answer virtual inquiries regarding medication dosage, storage, and shipping updates.
• Manage Inventory: Track and order digital pharmacy supplies for mail-order fulfillment centers.

• Processed Medicare Part B prior authorization and appeal requests in accordance with CMS and Aetna guidelines.
• Reviewed clinical documentation to determine medical necessity, coverage eligibility, and compliance requirements.
• Collaborated with providers, pharmacists, and internal teams to resolve issues and support approval/denial decisions.
• Utilized electronic systems to track, update, and process cases while maintaining strict HIPAA compliance.
• Utilize Epic, MedHOK (MHK), and RxClaims systems to review cases, process requests, and conduct pharmacy claims analysis.

• Conducted comprehensive benefit investigations for diabetic supplies, such as Omnipod Insulin Management System and Dexcom Continuous Glucose Monitoring System.
• Verified patient eligibility, coverage criteria, and cost-sharing across Commercial, Medicare, and Medicaid plans.
• Initiated and tracked prior authorizations for durable medical equipment (DME) and pharmacy benefits, ensuring accuracy and timely processing.
• Coordinated patient access by working closely with providers, suppliers, specialty pharmacies, and insurance payers.

• Verizon agent that receives and processes incoming phone calls for clients, which includes obtaining, entering, and verifying customer information (names, addresses, credit card numbers, etc.), answering questions, resolving issues, providing customer service, adhering to scripts, and attempting to make up-sells.
• Ensure that calls are processed in strict adherence to established policies, procedures, and quality standards, as well as any federal laws and regulations.
• Successfully complete initial on-the-job training, as well as any new product or on-going training.
• Process incoming calls manually in the event of computer system failure; and ensure quality or customer issues are escalated using established procedure and brought to resolution (chat, email, message boards, phone, etc.).

• United States courses included: All General Education, and Public speaking
• GPA: 3.8 - 4.0