Sr. Pharmacy Coordinator-1

Job ID: J135231
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Nov 2, 2018

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Description

JOB SUMMARY


This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services.  The incumbent will evaluate member profiles and claims histories.  Conducts telephonic outreach to the Gateway Health member population and providers.   Responds to provider and member inquiries concerning medication adherence or gap closure.   Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing coordination of benefits practices/procedures.

ESSENTIAL RESPONSIBILITIES

  • Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner.
  • Interact with staff to implement processes and problem solves.
  • Respond to  drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department..
  • Ensure adherence to call center turn around time requirements associated with DPW/CMS regulations.
  • Search member claim history profile and recommend formulary alternatives wherever feasible.
  • Contact physician network provider to obtain necessary and/or additional information when necessary.
  • Consult with staff clinical pharmacist for guidance and assistance as necessary.
  • Serve as a resource for technical staff.
  • Other duties as assigned or requested.


QUALIFICATIONS


Minimum

  • High school diploma or GED
  • Experience in pharmacy prescription claims processing/submission/payment

Preferred

  • Associate degree 
  • Pharmacy technician certification certificate   
  • Experience working in a managed care medication formulary management environment
  • Experienced working in a call center
  • Strong background and understanding of medications and formulary terminology
  • Bilingual preferred

Skills 

  • Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase 
  • Excellent interpersonal, communication and attentive listening skills
  • Strong organizational skills, detail oriented 
  • Demonstrated excellence in communication skills
  • Demonstrated ability to work well with others 
  • Demonstrated ability to work in a fast paced, multi-task environment

SCOPE OF RESPONSIBILITY  
Does this role supervise/manage other employees?

No 


WORK ENVIRONMENT

Is Travel Required?
No      

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Summary

This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services.  Serves as first line reviewer in monitoring and ensuring adherence to the health plan’s state and federal multiple drug benefit design offerings.  The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. Clearly defines the medical necessity of non-formulary and prior authorization medication exception requests,  by reviewing member claims history,.  Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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