Senior Pharmacy Coordinator

This is a fully remote position, open to applicants in Alabama, +47 more locations.

📋 Description

• Provide guidance to front-line staff and ensure the effective and efficient delivery of Pharmacy call center services.

• Act as the primary reviewer for compliance with state and federal drug benefit designs.

• Address inquiries from physicians and pharmacy network providers regarding requests for oral, injectable, and infusion medications, as well as drug claim edits and prior authorizations.

• Analyze member claims history to determine medical necessity for exceptions to non-formulary and prior authorization medication requests.

• Educate and support pharmacy network providers in resolving denied point-of-sale prescription claims and navigating coordination of benefits procedures.

• Communicate with providers to meet the needs of both providers and plan members.

• Collaborate with staff to implement processes and troubleshoot issues.

• Oversee and direct the daily workflow of the department.

• Prioritize requests for drug authorization and denial.

• Assess prior authorization criteria for various drug products.

• Suggest staffing changes to enhance efficiency and productivity.

• Ensure compliance with call center turnaround requirements as per DPW/CMS regulations.

• Evaluate requests for non-formulary drug exceptions prior to approval, authorization, or claim override.

• Review member claim histories and propose formulary alternatives.

• Reach out to physician network providers to gather additional information.

• Consult with clinical pharmacists when necessary.

• Accurately document authorizations and denials within regulatory timelines.

• Fill in authorization and denial fields in OnBase.

• Input authorizations into Argus IPNS for claim adjudication.

• Identify and report improper coordination-of-benefits billing practices during paid-claims reviews.

• Represent pharmacy in onsite member appeals and grievance sessions.

• Serve as a technical resource for staff.

• Complete other assigned responsibilities as required.

⛳️ Requirements

• High school diploma or GED.

• Experience in processing, submitting, and paying pharmacy prescription claims.

• Associate degree (preferred).

• Pharmacy technician certification (preferred).

• Experience in a managed care medication formulary management environment (preferred).

• Working knowledge of retail pharmacy and/or third-party prescription processing (preferred).

• Strong understanding of medications and formulary terminology (preferred).

• Familiarity with various Medicaid drug benefit designs and regulations across multiple states.

• Knowledge of Medicare drug benefit designs and relevant federal regulations.

• Excellent computer skills, including proficiency in Microsoft Outlook, Word, and OnBase.

• Exceptional interpersonal, communication, and active listening skills.

• Strong organizational abilities and attention to detail.

• Capability to collaborate effectively with others.

• Ability to thrive in a fast-paced, multi-tasking environment.

• Adherence to HIPAA, data security protocols, company policies, and applicable laws and regulations.

🏝️ Benefits

• Comprehensive health insurance plans.

• Retirement savings options with company matching.

• Generous paid time off and holiday schedule.

• Professional development opportunities.

• Collaborative and supportive work environment.