Remote Pharmacy Benefits Navigator

Remote Jobs; United States; Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Health benefits

Remote work setup

Competitive compensation

Job summary

AffirmedRx is seeking a Patient Care Advocate to serve as a trusted liaison between patients and healthcare providers, applying deep expertise in pharmacy benefits to ensure members receive the highest level of care and support. The PCA will exercise independent judgment, provide education and guidance, and resolve complex benefit questions to help members navigate the healthcare system with confidence.

The role requires strong communication, collaboration with internal and external

Qualifications

• 4+ years of proven experience in pharmacy benefits, managed care, or patient advocacy.
• Must reside in Washington or Oregon.
• Excellent communication and interpersonal skills.
• Ability to translate complex benefit information into clear guidance for members and providers.

Responsibilities

• Serve as subject matter expert on the pharmacy and medical benefit structures of all major payer types — Medicare, Medicaid, and commercial — and apply that expertise to interpret coverage and resolve complex benefit questions.
• Provide authoritative guidance across the full prior authorization and appeals process for prescription medications, exercising judgment to determine the appropriate course of action for each case.
• Assess patient eligibility for copay and financial assistance from public, private, and non-profit sources, and determine when and how to connect patients with third-party assistance.
• Interpret PBM regulations, policies, and industry developments, and use that analysis to advise patients and inform decisions.
• Independently assess complex benefit, coverage, and authorization questions from members and providers, determine the appropriate resolution strategy, and communicate guidance through applicable channels.
• Own cases end to end, exercising discretion to resolve issues and escalating only when circumstances warrant.
• Counsel members and patients on coverage, benefits, and financial assistance options, tailoring guidance to their individual circumstances.
• Partner with internal and external stakeholders — members, providers, and pharmacies — and coordinate community-based resources to remove barriers to care.
• Analyze claims against benefit guidelines, identifying discrepancies and determining appropriate corrective action.
• Conduct benefit verification and test claims to validate coverage and inform resolution.
• Maintain thorough, accurate documentation of case activity and the rationale behind decisions.
• Evaluate quality and identify trends across interactions and documentation, and recommend process improvements.

Skills

Pharmacy benefits knowledge

Prior authorization & appeals

Excellent communication

Independent judgment

Customer advocacy

Education

Bachelor's degree in healthcare-related field

Tools

Claims systems

Benefit verification systems

Case management software

Job description

AffirmedRx is seeking a Patient Care Advocate to serve as a trusted liaison between patients and healthcare providers, applying deep expertise in pharmacy benefits to ensure members receive the highest level of care and support. The PCA will exercise independent judgment, provide education and guidance, and resolve complex benefit questions to help members navigate the healthcare system with confidence.

The role requires strong communication, collaboration with internal and external