Highmark Inc. is seeking a Pharmacy Coordinator Senior to provide front-line staff guidance and ensure the effective delivery of Pharmacy call center services. You will serve as a first-line reviewer for drug benefit design adherence and respond to provider inquiries regarding medication requests and claim edits.
What You'll Do
- Communicate effectively with physician and pharmacy network providers to address needs courteously and timely.
- Interact with staff to implement processes and problem-solve operational challenges.
- Respond to drug benefit design inquiries and exception requests, evaluating and directing daily workflow.
- Prioritize requests for drug authorizations or denials.
- Review prior authorization criteria for drug products.
- Recommend staffing adjustments to maintain high efficiency and productivity.
- Ensure adherence to call center turnaround time requirements associated with DPW/CMS regulations.
- Perform complete and accurate evaluation of all non-formulary drug exception requests prior to approval.
- Search member claim history profiles and recommend formulary alternatives.
- Contact physician network providers to obtain necessary additional information.
- Consult with staff clinical pharmacists for guidance and assistance.
- Document all authorizations and denials completely, accurately, and in accordance with regulations.
- Populate all authorization and denial information fields within the OnBase information system.
- Enter all authorizations into the Argus IPNS system to allow claim adjudication.
- Identify and report improper coordination of benefit billing practices through paid claims review.
- Participate as a pharmacy representative in onsite member appeals and grievances sessions.
- Serve as a resource for technical staff.
What We're Looking For
- High school diploma or GED.
- Experience in pharmacy prescription claims processing, submission, or payment.
Nice to Have
- Associate degree.
- Pharmacy technician certification.
- Experience working in a managed care medication formulary management environment.
- Working knowledge of retail pharmacy and/or third-party prescription processing.
- Strong background and understanding of medications and formulary terminology.
- Familiarity with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states.
- Familiarity with Medicare drug benefit design offerings and applicable federal rules/regulations.
Technical Stack
- Microsoft Outlook
- Microsoft Word
- OnBase
Benefits & Compensation
- Compensation: $19.27-$26.88 per hour.
Work Mode
This is an onsite position.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
