Pharmacy Operations Coordinator- Remote

About the role

The Pharmacy Operations Coordinator performs oversight and monitoring of the pharmacy benefit manager (PBM), ensures appropriateness of claims adjudication, and supports CMS regulatory requirements and other Plan Operations.

Responsibilities

• Serve as primary contact between Plan and PBM.
• Perform PBM oversight and monitoring.
• Report and escalate performance deficiencies and status to management and the compliance department.
• Formulary Management: recognize formulary requirements (non-formulary, prior authorization, Step Therapy, Quantity Limit) and review, outreach, and track rejected pharmacy claims.
• Ensure regulatory requirements are met for coverage determinations/redeterminations.
• Lead annual readiness activities.
• Serve as a liaison with Enrollment Department to ensure appropriate member eligibility processing.
• Support CMS Plan reporting, audits, and monitoring activities and submissions.
• Assist and track in-coming calls from agents, pharmacies, nursing homes, providers/nurses, and members.
• Coordinate monthly website updates.
• Monitor and report on departmental metrics.
• May be assigned to work on special projects and business initiatives.
• Other duties as assigned.

Requirements

• Maintain regular and reliable attendance.
• Attention to detail.
• Ability to work in a high-demand, fast-paced environment.
• Experience in planning and implementation.
• Strong analytical skills.
• Strong leadership and collaboration skills.
• Extensive knowledge in Medicare compliance.
• Customer and quality focus.
• Follow-up and solve open items in a timely manner.
• Adhere to all compliance requirements and CMS regulations.
• Successful completion of required training.
• Handle multiple priorities effectively.
• Independent discretion/decision making.
• Make decisions under pressure.

Qualifications

• Education: High school diploma or equivalent required.
• Experience: Experience in the pharmacy department of a Medicare Advantage or Part D plan is preferred.
• License/Certification(s): Pharmacy technician certification.