Pharmacy Program Specialist

JOB SUMMARY

Under the direction of the Director of Pharmacy Analytics, functions as a Pharmacy Program Specialist in the Pharmacy Analytics department. Provides efficient and accurate responses to external customers (physicians, office staff, pharmacy providers, members, and brokers), and internal team members. Resolves outpatient pharmacy benefit coverage and prescription claim problems. Communicates drug formulary guidelines, including drug formulary alternatives, prior authorization criteria, and group/member eligibility problems.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Assist with processing medication prior authorization and appeal requests within required turn-around time.
• Maintain and process medication override requests-Communicate authorization and medication approval to Pharmacy Benefit Manager within required turn-around time.
• Answer questions regarding pharmacy benefit and coverage of medical injectables under medical benefit.
• Resolve coverage issues with Pharmacy Benefit Manager pertaining covered drugs, copays, medication prior authorization requests and medication appeals.
• Make outreach to members and providers as directed to improve medication adherence.
• Afford assistance in generating reports and performing monitoring over delegated PBM functions as directed.
• Make outreach to members and providers as directed to resolve issues with medical requests within required turn-around time.
• Actively contribute to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plan, and other duties as assigned.

QUALIFICATIONS

• Education/Specialized Training/Licensure: HS Diploma or GED
• Registered with the Texas State Board of Pharmacy as a pharmacy technician and in good standing (CPhT) required.
• Bachelor's degree preferred.
• Work Experience (Years and Area): 1 year in related functions required.
• Minimum of 1 year experience with a health plan or PBM preferred.
• Management Experience (Years and Area): N/A
• Software Proficiencies: Microsoft Office