Pharmacy Benefits Specialist: Prior Authorization & Formulary

Aditi Consulting; Rancho Cordova (CA); On-site; USD 28,000 - 30,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) plan with employer match

Paid time off

Bereavement leave

Job summary

Aditi Consulting is hiring for a Pharmacy Benefits Coordinator to support the outpatient drug prior authorization program and resolve formulary and coverage issues. The role focuses on communication with physicians, office staff, and cross-functional teams to ensure accurate and timely prior authorization decisions.

Responsibilities include providing formulary alternatives, assisting with drug utilization and NCQA programs, and researching inquiries to aid in case reviews and approvals.

Qualifications

• Currently in training or recently completed training but has not consistently reached production/quality standards
• 2-4 years' experience required.

Responsibilities

• Under general supervision, coordinates, assists in and supports implementation of procedures and guidelines for the drug prior authorization program for the outpatient Pharmacy Benefit.
• Communicates with the physician, physician's office staff, medical management and other Cross team members to assist with accurate and efficient resolution of prior authorization requests
• Assists in providing formulary alternatives and communicates prior authorization criteria, and discusses pharmacy benefit coverage inclusions/exclusions when required
• Interfaces in a courteous and professional manner with physicians, physician office staff, contracted pharmacists, patients, and other Cross team members during the prior authorization process
• Provides drug usage history and other pertinent pharmacy benefit related computer searches for pharmacists and Medical Director to assist in case specific reviews and drug evaluations.
• Assists pharmacists with drug utilization review programs, NCQA QI programs or other assigned projects
• Communicates prior authorization criteria, pharmacy benefit coverage and formulary alternatives to physician, physician office staff, medical management staff, sales, member/customer services
• Assists in research and resolution of physician inquiries and grievances
• Provides essential clinical information to Member Services, Administrative Review Department and Consumer Affairs to resolve Member inquires and grievances

Skills

Prior authorization

Formulary knowledge

Pharmacy benefits

Communication skills

Job description

Aditi Consulting is hiring for a Pharmacy Benefits Coordinator to support the outpatient drug prior authorization program and resolve formulary and coverage issues. The role focuses on communication with physicians, office staff, and cross-functional teams to ensure accurate and timely prior authorization decisions.

Responsibilities include providing formulary alternatives, assisting with drug utilization and NCQA programs, and researching inquiries to aid in case reviews and approvals.