Pharmacy Program Specialist II

Job Summary

The Pharmacy Program Specialist II performs criteria-based review of pharmacy and medical benefit requests in accordance with established clinical guidelines, plan policies, and prior authorization protocols. The role requires a strong understanding of pharmacy and medical benefit drug coverage, and adherence to regulatory timelines. The specialist also contributes to reporting, monitoring delegated PBM functions, and promoting member adherence, while delivering a high level of customer service.

Job Specifications and Core Competencies

Prior Authorization and Criteria-Based Review

• Process prior authorization requests according to established criteria and protocol within defined turnaround time standards
• Review pharmacy and medical benefit requests against established clinical criteria, plan policies, and authorization guidelines
• Ensure completeness and accuracy of submitted documentation prior to escalation
• Identify and escalate incomplete, non-compliant, or exception-based requests to appropriate clinical reviewer

PBM Coordination and Workflow Support

• Cookordinate with PBM and internal departments to support authorization workflows
• Track request status and ensure adherence to service level requirements
• Communicate and effectuate request outcomes based on established determinations and protocol

Reporting and Monitoring Support

• Support tracking of prior authorization volumes, turnaround times, and workflow performance
• Assist in monitoring delegated functions and identifying operational variances
• Maintain documentation to support audit readiness and compliance requirements

Qualifications

• Education/Specialized Training/Licensure: Bachelor's degree in healthcare field, or in business administration required.
• Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technician required.
• Work Experience (Years and Area): Minimum Three (3) years' experience with a Health Plan or PBM in related functions.
• Strong experience with prior drug authorization process in a Health Plan or PBM
• Management Experience (Years and Area): N/A
• Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point)
• Visio preferred.

Competencies

• Problem Analysis
• Results Oriented
• Attention to Detail
• Leadership

Technical Competencies

• Ability to accurately apply predefined clinical criteria and guidelines
• Strong understanding of prior authorization workflows and escalation protocols
• Knowledge of PBM processes and delegated function structures
• Analytical and Process Skills
• Attention to detail in criteria-based review and documentation validation
• Ability to identify when a request falls outside established criteria
• Compliance and Risk Awareness
• Understanding of scope-of-role limitations
• Ability to appropriately escalate clinical decisions to licensed pharmacist or appropriate clinical reviewer

Interpersonal Skills

• Ability to explain and communicate complex ideas with a diverse population