Sentara Health Plans is looking to hire Pharmacy Prior Authorization Coordinator 1:
This is a remote position: Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming
Shift: Monday- Friday from 8:00am to 8:00pm and must be flexible to work on weekends.
The Pharmacy Prior Authorization Coordinator I is responsible for delivering high-quality customer service by answering and managing calls from members, provider offices, and pharmacies. This role supports the processing of prior authorization (PA) requests for pharmacy benefit medications, ensuring accuracy, compliance with regulatory and clinical guidelines, and alignment with client performance standards. The Coordinator I works under general supervision, using established protocols and systems to support timely, efficient, and accurate PA determinations.
This role uses various business systems and tools to retrieve information, analyze requests, and enter prior authorization data required for claims adjudication. The Coordinator I applies reasoning skills to identify incomplete information and determine appropriate actions based on client-specific criteria and clinical protocols (e.g., approve, pend, refer for clinical decision). The position interacts regularly with internal teams and external stakeholders to ensure consistent, high-quality service delivery. Work is performed under general supervision, with reliance on documented procedures, training, and prior experience to guide day-to-day activities.
Key Responsibilities
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Verify member insurance eligibility and pharmacy benefit coverage.
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Communicate with members and providers regarding basic pharmacy inquiries and PA status.
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Accurately enter and process prior authorization (PA) requests into the system, prioritizing appropriately.
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Ensure PA requests are processed and finalized within required turnaround times (TAT) and client Performance Guarantees (PGs), using provided clinical guidelines.
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Review medication history and assess for formulary alternatives and “tried and failed” drugs.
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Document all relevant PA information clearly and accurately, including approval or denial rationale.
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Send PA status updates to providers and pharmacies via fax or other required methods.
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Adhere to defined roles and responsibilities related to clinical decision-making boundaries.
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Meet or exceed productivity and accuracy targets for PA processing.
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Coordinate with members, providers, and pharmacies to obtain missing information or clarification.
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Make outbound calls to gather additional information or respond to inquiries related to PAs, clinical programs, or claim adjudication.
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Collaborate with Pharmacy Concierge teams to resolve questions or issues related to PA processing or pharmacy benefits.
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Maintain strict confidentiality and security of all member and PA-related data, following applicable protocols for data handling and storage.
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In addition to the above responsibilities, other duties may be assigned.
Education
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High School Diploma or GED strongly preferred.
Experience
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1 year healthcare experience required.
We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is: $19.04/HR – $31.73/HR. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities
