Pharmacy Care Coordinator

SHIFT:

Day (United States of America)

Seeking Breakthrough Makers

Children's Hospital of Philadelphia (CHOP) offers countless ways to change lives. Our diverse community of more than 20,000 Breakthrough Makers will inspire you to pursue passions, develop expertise, and drive innovation.

At CHOP, your experience is valued; your voice is heard; and your contributions make a difference for patients and families. Join us as we build on our promise to advance pediatric care-and your career.

CHOP does not discriminate on the basis of race, color, sex, national origin, religion, or any other legally protected categories in any employment, training, or vendor decisions or programs. CHOP recognizes the critical importance of a workforce rich in varied backgrounds and experiences and engages in ongoing efforts to achieve that through equally varied and non-discriminatory means.

A Brief Overview
The Pharmacy Care Coordinator (PCC) ensures timely patient access to medication therapies by managing benefit verification, prior authorizations, reauthorizations, and appeals. This role will handle inbound calls (may include serving as a call center resource), triaging issues, providing explanations of benefits structures and copay assistance programs, and resolving complex coverage barriers. The PCC partners closely with patients, providers/clinic staff, payors, and internal and/or external pharmacies, while accurately documenting all activity in the electronic health record (EHR) through final authorization determination.

What you will do

• 1. Verify pharmacy and/or medical benefits using third party benefit coverage/authorization vendors to determine pharmacy eligibility and appropriate dispensing pharmacy.
• 2. Perform billing and/or claim adjudication and identify coverage status, payor restrictions, servicing pharmacy options, and determine next steps for order escalation as needed including but not limited to: Prior Authorization, Benefits Investigation, Step Therapy, Non-Formulary, Financial Assistance, and Copay-assistance programs.
• 3. Submit, track, and follow up on prior authorizations, reauthorizations, and appeals in accordance with payor specific requirements.
• 4. Follow up with insurance companies, providers/clinic staff and patients/families regarding therapies that are identified as ineligible or non-covered.
• 5. Contact provider/clinic staff with all information that requires follow-up.
• 6. Answer inbound calls (may include serving as a call center resource) and triaging patient, provider, and payor inquiries to the appropriate teams.
• 7. Coordinate with provider/clinic staff, pharmacies, and payors to ensure continuity of care and timely access to therapy.
• 8. Communicate authorization status, coverage limitations, and outstanding financial obligations if appropriate, and next steps clearly to patients, families, and providers/clinic staff.
• 9. Accurately document all activities, communications, and determinations in the EHR
• 10. Refer eligible patients to CHOP's comprehensive pharmacy program that includes retail, specialty and home infusion pharmacies and identify cases requiring referral to external pharmacies and notify providers/clinic staff using established documentation and communication standards.
• 11. Adhere to organizational policies, payor contracts, and regulatory requirements.
• 12. Participate in departmental quality assurance and improvement initiatives.
• 13. Perform other duties as assigned by Management.

Education Qualifications

• High School Diploma / GED Required
• Bachelor's Degree Preferred

Experience Qualifications

• At least two (2) years relative job experience Required

Skills and Abilities

• Ability to work with stressful situations (Required proficiency)
• Strong interpersonal, written, and verbal communication skills, with the ability to deliver professional, high quality customer service to patients, families, providers, payers, and clinical staff in person and by phone. (Required proficiency)
• Demonstrated ability to work efficiently and professionally with minimal supervision in a fast paced, metrics driven environment. (Required proficiency)
• Proficiency with computers and Microsoft 365 applications, with the ability to quickly learn and apply new systems, tools, and procedures. (Required proficiency)
• Ability to manage multiple cases simultaneously, prioritize workload, and adapt to changing departmental needs, including supporting team members and adjusting assignments as needed. (Required proficiency)
• Knowledge of commercial, Medicaid, and Medicare insurance plans, including an understanding of program requirements and coverage processes. (Required proficiency)
• Ability to consistently demonstrate CHOP ICARE values-Integrity, Compassion, Accountability, Respect, and Excellence-in all interactions and work practices, including displaying compassion and empathy when supporting patients and families. (Required proficiency)
• Strong organizational skills, critical thinking ability, and attention to detail, with the ability to solve problems, make informed decisions, and ensure accurate documentation and data entry in compliance with payer requirements. (Required proficiency)
• Proficiency using electronic health records (EHRs) and pharmacy systems (e.g., Epic Hyperspace, Epic Willow, HDMS, or similar). (Required proficiency)
• Experience utilizing payer and insurance websites and tools (e.g., NaviNet, WebMD, Passport, Availity, CoverMyMeds, Surescripts, PromptPA, PEAR Portal, or similar platforms). (Required proficiency)
• Working knowledge of common medical terminology, abbreviations, and basic pharmacy calculations. (Required proficiency)

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must receive an annual influenza vaccine. Learn more.

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SALARY RANGE:

$25.50 - $31.85 Hourly

Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly.

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At CHOP, we are committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting. Click here for more information regarding CHOP's Compensation and Benefits.