Pharmacy Coordinator

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Pharmacy Coordinator - (Grievances, Appeals, and Prior Authorizations) Remote -- 10am - 6pm, 11am - 7pm or 12pm - 9pm Eastern / EST. Tuesday-Saturday or Sunday-Thursday

Position Purpose: Perform duties to support the efforts pharmacy department in the development, coordination and maintenance of the health plan’s pharmacy program.

Receive and respond to provider and pharmacy calls regarding the prior authorization and formulary process

Perform review of pharmacy and override process in compliance with pharmaceutical related company and State guidelines

Track and trend overrides to ensure criteria have been met, audit for prior authorizations, analyze cost and determine utilization patterns

Resolve complaints and grievances related to the pharmacy network in conjunction with the Pharmacy team

Assist Provider Relations and various departments with educating providers on the health plan’s pharmacy process

Assist with the pharmacy utilization review and reporting process

Collaborate with Quality Improvement department with various meeting preparation and transcription of minutes

Assist with members’ inquiries related to the formulary process

For Centene Pharmacy Services
Education/Experience: High school diploma or equivalent.

3+ years of pharmacy experience, preferably in a managed care environment. Medicare and/or Medicaid experience preferred. Advanced Microsoft office experience preferred (Excel, Word, PowerPoint, Visio). Prior experience using analysis tools or systems (ex: web based, custom, proprietary, etc.). Experience in the implementation of quality process improvement efforts. Experience documenting requirements, creating training materials and working directly with end users. Excellent verbal and written communication skills. Strong analytical skills with attention to detail. Ability to exercise independent judgment. Ability to manage deliverables in a high pace environment.

License/Certificate: Current state's Pharmacy Technician license preferred.

Nationally Certified Pharmacy Technician (PTCB / NHA CPhT), highly preferred

Prior Authorization with Appeals experience, highly preferred.

Job specific responsibilities:

Processing Pharmacy Appeals from Medicaid and Marketplace.

Place outbound calls to inform member/provider of appeal determination.

Place outbound calls to inform members/providers if additional documentation is needed.

Set up the appeals to have them reviewed by a RPh or Medical Director.

Identifying valid appeals and invalid appeals

Correctly verify drug, dosage, quantity, provider, diagnosis information.

Review prior authorization criteria to that is used in denial.

Enter overrides for approvals as Vendor and Biopharmacy.

Working shift: Flexible to work 10am-6pm, 11am-7pm or 12pm-9pm (Eastern / EST). Tuesday-Saturday (with Sunday/Monday off) Sunday-Thursday (with Friday/Saturday off).

The Saturday or Sunday shifts are 8am – 4:30pm or 9:30pm – 6pm (EST)

No earlier shift or Monday – Friday available. The actual shift will be assigned by team at time of offer.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.