Pharmacy Program Specialist II

About Us Community Health Choice, Inc. (Community) is a Non‑profit Managed Care Organization (MCO), licensed by the Texas Department Of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 members with the following programs: Medicaid State of Texas Access Reform (STAR) program for low‑income children and pregnant women Children’s Health Insurance Program (CHIP) for children of low‑income parents, including CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre‑existing conditions Community Health Choice (HMO D‑SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more The mission is to improve members’ experiences by ensuring access to high‑quality health care. Community is accredited by URAC for its health‑plan operations, offers care management programs for asthma, diabetes, and high‑risk pregnancy, and is financially independent. 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. The position does not exercise independent clinical judgment or make final adverse determinations, and all requests requiring clinical discretion are routed to a licensed pharmacist or appropriate clinical reviewer. 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 Route requests that require clinical judgment or exception review to a licensed pharmacist or appropriate clinical reviewer Identify and elevate incomplete, non‑compliant, or exception‑based requests to appropriate clinical reviewer PBM Coordination and Workflow Support Coordinate 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 Other duties as assigned Qualifications Education: Bachelor’s degree in a healthcare field or in business administration (required) Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technician (required) Minimum three (3) years of experience with a health plan or PBM in related functions Strong experience with prior drug authorization processes in a health plan or PBM Software proficiency: Microsoft Office (Word, Excel, Outlook, PowerPoint); Visio preferred Clinical decision authority limitation: this position performs criteria‑based review functions only and does not independently override established criteria or render adverse clinical determinations Competencies Problem Analysis Results Oriented Attention to Detail Leadership Additional Competencies Technical Competencies 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 elevate clinical decisions to licensed pharmacist or appropriate clinical reviewer Interpersonal Skills Ability to explain and communicate complex ideas with a diverse population #J-18808-Ljbffr Harris Health