Pharmacy Care Coordinator - 1

About the role

The Pharmacy Care Coordinator (PCC) ensures timely patient access to medication therapies by managing benefit verification, prior authorizations, reauthorizations, and appeals. This role will handle inbound calls, triaging issues, providing explanations of benefits structures and copay assistance programs, and resolving complex coverage barriers. The PCC partners closely with patients, providers/clinic staff, payors, and internal and/or external pharmacies, while accurately documenting all activity in the electronic health record (EHR) through final authorization determination.

Responsibilities

• Verify pharmacy and/or medical benefits using third party benefit coverage/authorization vendors to determine pharmacy eligibility and appropriate dispensing pharmacy.
• Perform billing and/or claim adjudication and identify coverage status, payor restrictions, servicing pharmacy options, and determine next steps for order escalation as needed.
• Submit, track, and follow up on prior authorizations, reauthorizations, and appeals in accordance with payor specific requirements.
• Follow up with insurance companies, providers/clinic staff and patients/families regarding therapies that are identified as ineligible or non-covered.
• Contact provider/clinic staff with all information that requires follow-up.
• Answer inbound calls and triaging patient, provider, and payor inquiries to the appropriate teams.
• Coordinate with provider/clinic staff, pharmacies, and payors to ensure continuity of care and timely access to therapy.
• Communicate authorization status, coverage limitations, and outstanding financial obligations if appropriate, and next steps clearly to patients, families, and providers/clinic staff.
• Accurately document all activities, communications, and determinations in the EHR.
• Refer eligible patients to CHOP’s comprehensive pharmacy program and identify cases requiring referral to external pharmacies and notify providers/clinic staff using established documentation and communication standards.
• Adhere to organizational policies, payor contracts, and regulatory requirements.
• Participate in departmental quality assurance and improvement initiatives.
• Perform other duties as assigned by Management.

Qualifications

A High School Diploma or GED is required, while a Bachelor's Degree is preferred. At least two years of relative job experience is required.

Skills

• Ability to work with stressful situations.
• Strong interpersonal, written, and verbal communication skills.
• Demonstrated ability to work efficiently and professionally with minimal supervision in a fast-paced environment.
• Proficiency with computers and Microsoft 365 applications.
• Ability to manage multiple cases simultaneously, prioritize workload, and adapt to changing departmental needs.
• Knowledge of commercial, Medicaid, and Medicare insurance plans.
• Ability to consistently demonstrate CHOP ICARE values.
• Strong organizational skills, critical thinking ability, and attention to detail.
• Proficiency using electronic health records (EHRs) and pharmacy systems.
• Experience utilizing payer and insurance websites and tools.
• Working knowledge of common medical terminology, abbreviations, and basic pharmacy calculations.

Pay

The hourly salary range for this position is $25.50 - $31.85. Salary ranges are shown for full-time jobs and will be adjusted accordingly for part-time positions.

Schedule

This is a day shift position in the United States of America.

Benefits

CHOP offers a comprehensive benefits package, including a compensation and benefits program that is committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting.