Pharmacy Operations Coordinator

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Act as the main liaison between the Plan and the pharmacy benefit manager (PBM).

• Oversee and monitor PBM operations.

• Report and escalate performance issues and status updates to management and the compliance department.

• Review, reach out, and track denied pharmacy claims related to non-formulary, prior authorization (PA), Step Therapy (ST), and Quantity Limit (QL) requirements.

• Ensure compliance with regulatory requirements for coverage determinations and redeterminations.

• Lead annual preparation activities.

• Collaborate with the Enrollment Department to ensure proper processing of member eligibility.

• Assist with CMS Plan reporting, audits, monitoring activities, and submissions.

• Help manage and track incoming calls from agents, pharmacies, nursing homes, providers/nurses, and members.

• Coordinate updates to the website on a monthly basis.

• Monitor and report on departmental metrics.

• Participate in special projects and business initiatives as assigned.

• Perform additional duties as required.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Pharmacy technician qualification/license/certification is required.

• Experience in the pharmacy department of a Medicare Advantage or Part D plan is preferred.

• Maintain consistent and reliable attendance.

• Strong attention to detail.

• Ability to thrive in a high-demand, fast-paced environment.

• Experience in planning and implementation.

• Strong analytical capabilities.

• Excellent leadership and collaboration skills.

• In-depth knowledge of Medicare compliance.

• Focus on customer service and quality.

• Proactively follow up and resolve outstanding issues in a timely manner.

• Comply with all regulatory requirements and CMS regulations.

• Successfully complete all required training.

• Effectively manage multiple priorities.

• Exercise independent judgment and decision-making.

• Make informed decisions under pressure.

🏝️ Benefits

• Comprehensive health insurance plans.

• 401(k) retirement plan with company matching.

• Paid time off and holidays.

• Opportunities for professional development and career advancement.

• Supportive work environment.