Senior Pharmacy Coordination Specialist - Remote

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

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.