Pharmacy Coordinator Senior

Highmark Health Company; Pennsylvania; Hybrid; USD 27,000 - 38,000; Full time

Job summary

Highmark Inc. is seeking a Pharmacy Claims Specialist to guide frontline staff, review drug benefit design requests, and ensure accurate processing of prescriptions and authorizations.

The role supports physicians and network providers, ensuring regulatory compliance and efficient workflows in a remote setting. The position requires prior claims processing experience, familiarity with Medicaid/Medicare rules, and strong communication skills to collaborate with clinical staff and payors.

Qualifications

• Experience in pharmacy prescription claims processing/submission/payment.
• Familiarity with Medicaid/Medicare benefit design offerings.
• Strong computer and OnBase knowledge.
• Experience in managed care formulary environments.

Responsibilities

• Communicate effectively with physician and pharmacy network providers to address needs in a courteous, timely manner.
• Interact with staff to implement processes and solve problems.
• Respond to drug benefit design inquiries or exception requests and manage daily workflow.
• Prioritize requests for drug authorizations or denials.
• Review prior authorization criteria for drug products.
• Recommend staffing adjustments to maintain high efficiency.
• Ensure adherence to call center turnaround times per DPW/CMS regulations.
• Evaluate non-formulary drug exception requests prior to approval.
• Search member claim history and suggest formulary alternatives.
• Contact physician network providers for information as needed.
• Consult with staff pharmacist for guidance as necessary.
• Document authorizations/denials accurately per regulations.
• Populate OnBase fields for authorizations/denials.
• Enter authorizations into Argus IPNS.
• Perform other duties as assigned.
• Identify improper coordination of benefit billing in paid claims.

Skills

Pharmacy claims processing

Communication skills

Team collaboration

Attention to detail

Problem solving

Education

High school diploma or GED

Pharmacy technician certification

Tools

OnBase

Argus IPNS

Microsoft Office

Job description

Company

Company : Highmark Inc.

Job Description

JOB SUMMARY This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. Clearly defines the medical necessity of non-formulary and prior authorization medication exception requests, by reviewing member claims history,. Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.

Work Schedule for this position is Monday/Wednesday/Friday 8:30 AM - 5:00 PM EST & Tuesday/Thursday 9:00 AM - 5:30 PM EST

ESSENTIAL RESPONSIBILITIES

• Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner.
• Interact with staff to implement processes and problem solves.
• Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department.
• Prioritize requests for drug authorizations or denials.
• Review of prior authorization criteria for drug products.
• Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity.
• Ensure adherence to call center turn around time requirements associated with DPW/CMS regulations.
• Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override.
• Search member claim history profile and recommend formulary alternatives wherever feasible.
• Contact physician network provider to obtain necessary and/or additional information when necessary.
• Consult with staff clinical pharmacist for guidance and assistance as necessary.
• Document all authorizations and denials completely and accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member.
• Populate all authorization and denial information fields within the OnBase information system.
• Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
• Complete other assigned duties as specified.
• Identify and report improper coordination of benefit billing practices through paid clams review.
• Participate as pharmacy representative in onsite member appeals and grievances sessions.
• Serve as a resource for technical staff.
• Other duties as assigned or requested.

QUALIFICATIONS

• Minimum High school diploma or GED
• Experience in pharmacy prescription claims processing/submission/payment
• Preferred Associate degree Pharmacy technician certification certificate
• Experience working in a managed care medication formulary management environment
• Working knowledge of retail pharmacy and/or third party prescription procession
• Strong background and understanding of medications and formulary terminology
• Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states.
• They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation.
• Skills Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
• Excellent interpersonal, communication and attentive listening skills
• Strong organizational skills, detail oriented
• Demonstrated excellence in communication skills
• Demonstrated ability to work well with others
• Demonstrated ability to work in a fast paced, multi-task environment

Position Type: Remote/Work from Home

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees? No

WORK ENVIRONMENT

Is Travel Required? No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum: $19.66 Pay Range Maximum: $27.42 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.