Pharmacy Program Specialist

Community Health Choice; Houston (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

Community Health Choice is seeking a Pharmacy Program Specialist to join our Pharmacy Analytics team. You will help members and providers navigate benefits, medication coverage, prior authorizations, appeals, prescription claims, and formulary requirements.

If you're detail-oriented and knowledgeable about pharmacy operations, you'll work with PBMs, providers, members, and internal teams to resolve issues and help ensure access to medications.

Qualifications

• High school diploma or GED required.
• Active Texas State Board of Pharmacy registration as a CPhT in good standing.
• At least one year of experience in pharmacy or related function.
• Proficiency with Microsoft Office.

Responsibilities

• Assist with processing medication prior authorization and appeal requests within required regulatory timeframes.
• Review and process medication override requests and communicate authorization and approval information to the PBM.
• Respond to questions from physicians, pharmacy providers, members, brokers, and internal teams regarding pharmacy benefits and medication coverage.
• Help resolve prescription claim and coverage issues involving covered medications, copays, prior authorizations, appeals, and member eligibility.
• Provide information regarding drug formulary, formulary alternatives, and prior authorization criteria.
• Answer questions regarding pharmacy benefits and medical injectable coverage under the medical benefit.
• Coordinate with the PBM to research and resolve pharmacy benefit issues.
• Conduct outreach to members and providers to improve medication adherence and resolve issues.
• Assist with reporting and monitoring of delegated PBM functions.
• Support departmental performance and process improvement initiatives.
• Perform other duties as assigned.

Skills

Microsoft Office

Pharmacy operations knowledge

Problem solving

Education

High school diploma or GED

CPhT certification with Texas State Board of Pharmacy

Job description

Put Your Pharmacy Expertise to Work in a New Way

Community Health Choice is seeking a Pharmacy Program Specialist to join our Pharmacy Analytics team. This is an excellent opportunity for a Certified Pharmacy Technician who wants to expand their career beyond a traditional pharmacy setting and gain experience on the health plan side of pharmacy benefits.

In this role, you'll help members and providers navigate pharmacy benefits, medication coverage, prior authorizations, appeals, prescription claims, and formulary requirements. You'll work closely with our Pharmacy Benefit Manager (PBM), providers, pharmacies, members, and internal teams to resolve issues and help ensure members have appropriate access to their medications.

If you're detail-oriented, knowledgeable about pharmacy operations, and enjoy solving problems and helping people, we'd like to hear from you.

Responsibilities:

• Assist with processing medication prior authorization and appeal requests within required regulatory timeframes.
• Review and process medication override requests and communicate authorization and approval information to the Pharmacy Benefit Manager (PBM).
• Respond to questions from physicians, pharmacy providers, members, brokers, and internal teams regarding pharmacy benefits and medication coverage.
• Help resolve prescription claim and coverage issues involving covered medications, copays, prior authorizations, appeals, and member eligibility.
• Provide information regarding drug formularies, formulary alternatives, and prior authorization criteria.
• Answer questions regarding pharmacy benefits and medical injectable coverage under the medical benefit.
• Coordinate with the PBM to research and resolve pharmacy benefit issues.
• Conduct outreach to members and providers to help improve medication adherence and resolve medication-related issues.
• Assist with reporting and monitoring of delegated PBM functions.
• Support departmental performance and process improvement initiatives.
• Perform other duties as assigned.

Required Qualifications:

• High school diploma or GED.
• Active registration with the Texas State Board of Pharmacy as a Certified Pharmacy Technician (CPhT) and in good standing.
• At least one year of experience in pharmacy or a related function.
• Proficiency with Microsoft Office.

Preferred Qualifications:

• At least one year of experience working with a health plan or Pharmacy Benefit Manager (PBM).
• Experience with medication prior authorizations, appeals, pharmacy benefits, prescription claims, or formulary management.
• Familiarity with managed care pharmacy operations.

Bring Purpose to Your Pharmacy Career

At Community Health Choice, our work is about more than administering health benefits. As a nonprofit health plan, we're committed to improving the health and well-being of Texans, especially underserved communities.

As a Pharmacy Program Specialist, you'll put your pharmacy knowledge into practice every day, helping members and providers navigate benefits, resolve barriers, and support better access to needed medications.

Purpose in Practice. It starts with you.

Community employees benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.

Community is an Equal Opportunity Employer.

Harris Health System's benefits program is designed to provide you with more flexibility and choices in meeting your specific needs. Harris Health System's benefits program allows you to protect your income in case of illness, death and disability, and to help you save for retirement.

It is the policy of Harris Health System to provide equal opportunity for all applicants for employment regardless of political affiliation, race, color, national origin, age, sex, religious creed or disability. Applicants may request any reasonable accommodation(s) to participate in the application process.