Pharmacy Coordinator

Pharmacy Coordinator

Location (City, State): San Jose, CA

Department: Pharmacy - 540

Employment Duration: full-time

Salary Range: $60,111 - $87,161 The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status: Non-Exempt

Reports To: Supervisor, Prior Authorization

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

General Description Of Position

The Pharmacy Coordinator reviews and processes prior authorizations through the determination process based on pharmacy clinical criteria/guidelines. Assists pharmacies and providers in resolving pharmacy claims processing and questions regarding prior authorizations in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures and business requirements. Performs non-clinical duties such as preparing departmental reports and analysis relating to formulary management, clinical programs, claims review, audits, and vendor oversight.

Essential Duties And Responsibilities

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

1. Perform complete, accurate and consistent prior authorization review requests for medications submitted by providers and/or pharmacies and approve based upon the pharmacy clinical criteria/guidelines.
2. Direct and refer prior authorization requests outside of established pharmacy clinical criteria/guidelines to Clinical Pharmacists.
3. Maintain on-going communication with pharmacies and physician offices, resolve technical processing issues, and escalate all outstanding issues.
4. Utilize appropriate approval and denial language on approval and denial letters.
5. Provide alternatives based on pharmacy clinical guidelines.
6. Assist Clinical Pharmacist with claims reports processing and review.
7. Assist Clinical Pharmacist with Pharmacy clinical programs developed within the Pharmacy department to outreach to members and/or providers to encourage medication adherence, reduce drug interactions, and enhance the level of care and outcomes for the members.
8. Assist Clinical Pharmacist with review of printed formularies, step criteria, and prior authorization guidelines.
9. Assist Clinical Pharmacist with formulary and benefit change submissions.
10. Assist Clinical Pharmacist in DHCS, DMHC, CMS, and department program audits.
11. Follow requirements to maintain compliance and participate in department self-audit procedures.
12. Assist doctors and pharmacies regarding prior authorization approval/denial questions.
13. Assist pharmacy department with claims processing, troubleshooting, and adjudication.
14. Assist customer service and pharmacies with appropriate overrides.
15. Assist pharmacies and providers with member eligibility and primary insurance status and forward information to the appropriate department.
16. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
17. Perform other related duties as required or assigned.

Requirements – Required (R)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High School Diploma or GED. (R)
2. Active Pharmacy Technician License without restriction. (R)
3. PTCB pharmacy certifications. (D)
4. Minimum two years of pharmacy experience in a managed care, hospital, long-term care, specialty compounding, infusion center, or retail pharmacy setting. (R)
5. Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
6. Knowledge of prior authorization (PA) or treatment authorization requests. (TAR) (R).
7. Knowledge of generic and brand name equivalents. Knowledge of Medi-Cal and Medicare prescription drug benefits and claims processing. (R)
8. Experience processing Medi-Cal, Medicare Part D, claims and Durable Medical Equipment (DME) authorizations. (D)
9. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
10. Working knowledge of and the ability to efficiently operate all applicable computer software including Outlook Word, Excel and PBM web based platform and general office equipment. (R)
11. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
12. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
13. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
14. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
15. Ability to maintain confidentiality. (R)
16. Ability to comply with all SCFHP policies and procedures. (R)
17. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

Working Conditions

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Physical Requirements

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

Environmental Conditions

General office conditions. May be exposed to moderate noise levels.

EOE