Address
Form of workPharmacy Coordinator
100% remote
2 Months+
Job Description:
Utilization Management (UM) Responsibilities:
Willingness to work 8-hour shifts between 8am and 7pm EST
Preferred Qualifications
100% remote
2 Months+
Job Description:
- The pharmacy team is looking for a highly motivated and energetic Coordinator, Pharmacy Operations to join the Pharmacy Services team.
- We are looking for team members that possess high-energy, a strong work ethic, integrity, who are kind and empathetic, have a sense of humor, and who enjoy working for a collaborative, team-oriented system.
- Responsibilities are varied as described below and dependent on business need.
- This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic working environment.
- Navigate across multiple systems to respond to questions from external and/or internal partners.
- Consistently meet established productivity requirements, adherence to schedule and quality standards.
- Always maintain confidentiality of protected patient medical information.
- Ability to adapt to a changing environment, including scheduling flexibility.
Utilization Management (UM) Responsibilities:
- Receive and review prescription prior authorization (PA) requests from providers and members via telephone, fax, email, and web-enabled submissions (e.g., electronic PA).
- Provide general prior authorization information via telephone, fax or email to providers, members and/or client partners.
- Perform outbound calls to provider and/or members to solicit information needed to process a prior authorization request, follow-up on PA requirements and/or provide consultation on the prior authorization program.
- Perform outbound notifications to members and/or providers notifying them of prior authorization outcomes.
- Review and approve, as applicable, member and provider inquiries for prior authorization requests based on established pharmacy guidelines and state and federal requirements.
- Perform quality review of prior authorization requests to ensure adherence of established pharmacy guidelines and state and federal requirements.
- Coordinate, compile and oversee the management of third-party external reviews for Medicare, Commercial and Medicaid lines of business.
- Process patient submitted Direct Member Reimbursement (DMR) claims and support the appeal and grievance process related to pharmacy clinical determinations.
Willingness to work 8-hour shifts between 8am and 7pm EST
Preferred Qualifications
- Certified pharmacy technician (CPhT)
- Associate or bachelor's degree
- Experience with MHK (formerly MedHOK)
- Experience at a health plan or PBM
- Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and ability to learn multiple work-related software applications
- Ability to make independent decisions
- Committed to team-oriented work environment
- Exceptional interpersonal, presentation, oral and written communication skills
- Strong work ethic built on a foundation of proactivity
- Committed to the practice of inquiry and listening
- Navigate ambiguity with structured problem-solving and decision-making
