Pharmacy Coordinator (Appeals)

Centene; United States; Remote; USD 10,000 - 60,000; Full time

Job summary

A leading healthcare organization seeks a clinical professional for its pharmacy department in Florida. The role involves managing pharmacy grievances, processing appeals, and supporting the pharmacy program. Candidates should have 3+ years of pharmacy experience and a high school diploma, with a preference for those with a Pharmacy Technician license.

Benefits

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements

Qualifications

• 3+ years of pharmacy experience required, preferably in managed care.
• Experience with analysis tools or systems.
• Current state's Pharmacy Technician license preferred.

Responsibilities

• Manage pharmacy grievances, appeals, and prior authorizations.
• Assist with pharmacy utilization review and reporting processes.
• Collaborate with Quality Improvement department.

Skills

Pharmacy experience

Analytical skills

Communication

Education

High school diploma or equivalent

Tools

Analysis tools

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Perform duties to support the efforts of the pharmacy department in the development, coordination, and maintenance of the health plan's pharmacy program.

1. Receive and respond to provider and pharmacy calls regarding the prior authorization and formulary process.
2. Perform review of pharmacy and override processes in compliance with pharmaceutical-related company and State guidelines.
3. Track and trend overrides to ensure criteria have been met, audit for prior authorizations, analyze costs, and determine utilization patterns.
4. Resolve complaints and grievances related to the pharmacy network in conjunction with the Pharmacy team.
5. Assist Provider Relations and various departments with educating providers on the health plan’s pharmacy process.
6. Assist with pharmacy utilization review and reporting processes.
7. Collaborate with the Quality Improvement department on meeting preparation and transcription of minutes.
8. Assist members with inquiries related to the formulary process.
9. Perform other duties as assigned.
10. Comply with all policies and standards.

Education / Experience

High school diploma or equivalent. 3+ years of pharmacy experience required, preferably in a managed care environment. Medicare and/or Medicaid experience is preferred. Prior experience with analysis tools or systems (e.g., web-based, custom, proprietary). Experience in implementing quality process improvements. Experience documenting requirements, creating training materials, and working directly with end users.

License/Certificate:

Current state's Pharmacy Technician license preferred (Florida). Nationally Certified Pharmacy Technician (PTCB or ExCPT) highly preferred.

Location:

Remote Florida only - Must reside in the state of Florida.

Schedule / Working Shift:

Open flexibility required - Full-time / 40 hours, 5 days/week. Availability from Sunday to Saturday, 8:00 AM – 7:00 PM (EST). Schedule includes at least one weekend shift (Saturday or Sunday) per week. Specific shifts to be determined based on business needs.

Job Specific Responsibilities:

• Manage pharmacy grievances, appeals, and prior authorizations.
• Process pharmacy appeals from Medicaid and Ambetter lines of business (Sunshine Health/FL Marketplace).
• Make outbound calls to inform members/providers of pharmacy appeal determinations and request additional documentation if needed.

Pay Range: $19.04 - $32.35 per hour.

Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and flexible work arrangements (remote, hybrid, field, or office schedules). Actual pay is based on skills, experience, education, and other factors as permitted by law. Total compensation may include additional incentives.

Centene is an equal opportunity employer committed to diversity. All qualified applicants will receive consideration regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics.

Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.