Salary Range: $61,554 - $89,253
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.
Temporary Position
FLSA Status: Non-Exempt
Department: Pharmacy
Reports to: Supervisor, Prior Authorization
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. Conduct daily review of denied pharmacy claims to ensure accuracy and identify trends and intervene as needed.
2. Perform telephonic member outreach to support Star Measures, including follow‑ups on denied PAs and medication refill reminders.
3. Support pharmacists by running, validating, and maintaining clinical program reports used for pharmacy quality initiatives.
4. Review UM authorization requests for diabetic testing supplies and continuous glucose monitors (CGM).
5. Support timely D-SNP Part D prior authorization effectuations.
6. Conduct quality assurance (QA) reviews to ensure accuracy for Medicare required marketing materials such as pharmacy network directory and formulary documents.
7. Review and support pharmacy grievance cases, ensuring timely resolution and compliance with regulatory timelines.
8. Provide responsive support to providers, Customer Service Representatives (CSR), and G&A teams regarding pharmacy operations and benefit inquiries.
9. Assist with various cross‑functional projects that enhance pharmacy operations, compliance, and member experience.
10. Perform other related duties as required or assigned.
REQUIREMENTS – Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
1. High School Diploma or GED. (R)
2. Current and active Pharmacy Technician License without restriction in CA.
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. Experience in health plan pharmacy operations, pharmacy benefits, prior authorization processes, and Medicare Part D preferred. (D)
6. 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)
7. Proficient in MS Excel and reports. (D)
8. Ability to work independently with minimal supervision while consistently meeting deadlines and performance expectations. (R)
9. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
10. 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)
11. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
12. Ability to effectively use telephone systems to place and receive calls in a professional manner. (R)
13. Ability to maintain confidentiality and comply with all SCFHP policies and procedures. (R)
14. 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:
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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)
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Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
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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)
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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)
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Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
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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
