Pharmacy Coordinator Senior

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Pharmacy Coordinator Senior

Work At Home - Pennsylvania, Home PA 90001, United States

Full time

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Job DescriptionWorking with UsBenefits & PerksHear From Our TeamHow We Hire

Job Details

Category Pharmacy

Type Full time

Location(s) Work At Home - Pennsylvania, Home PA 90001, United States

Brand Highmark Inc.

Posted 11/10/2026

Req ID J291268

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Job Description

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job provides front line staff guidance, ensures effective and efficient delivery of Pharmacy call center services. Serves as first line reviewer in monitoring and ensuring adherence to the health plan's state and federal multiple drug benefit design offerings. The incumbent responds to physician and pharmacy network provider inquiries concerning oral, injectable and infusion medication requests, and drug claim edits/prior authorizations. Clearly defines the medical necessity of non-formulary and prior authorization medication exception requests, by reviewing member claims history,. Interacts with pharmacy network providers to evaluate, educate and/or assist in addressing denied point of sale prescription claim transitions and coordination of benefits practices/procedures.

Work Schedule for this position is Monday/Wednesday/Friday 8:30 AM - 5:00 PM EST & Tuesday/Thursday 9:00 AM - 5:30 PM EST

ESSENTIAL RESPONSIBILITIES

• Communicate effectively with physician and pharmacy network providers to ensure that the needs of the provider and plan member are addressed in a courteous, helpful and timely manner.
• Interact with staff to implement processes and problem solves.
• Respond to drug benefit design inquires or exception requests and evaluate/direct daily workflow within the department.
• Prioritize requests for drug authorizations or denials.
• Review of prior authorization criteria for drug products.
• Recommend staffing adjustments necessary to appropriately maintain a level of high efficiency/productivity.
• Ensure adherence to call center turn around time requirements associated with DPW/CMS regulations.
• Take necessary steps to perform a complete and accurate evaluation of all non-formulary drug exception requests prior to approval, authorization or claim override.
• Search member claim history profile and recommend formulary alternatives wherever feasible.
• Contact physician network provider to obtain necessary and/or additional information when necessary.
• Consult with staff clinical pharmacist for guidance and assistance as necessary.
• Document all authorizations and denials completely and accurately, and in accordance with timelines as defined by state and federal regulations to insure appropriate notification issuance to prescribing physician and impacted member.
• Populate all authorization and denial information fields within the OnBase information system.
• Enter all authorizations into the Argus IPNS information system to allow claim adjudication.
• Complete other assigned duties as specified.
• Identify and report improper coordination of benefit billing practices through paid clams review.
• Participate as pharmacy representative in onsite member appeals and grievances sessions.
• Serve as a resource for technical staff.
• Other duties as assigned or requested.

QUALIFICATIONS

Minimum

• High school diploma or GED
• Experience in pharmacy prescription claims processing/submission/payment

Preferred

• Associate degree
• Pharmacy technician certification certificate
• Experience working in a managed care medication formulary management environment
• Working knowledge of retail pharmacy and/or third party prescription procession
• Strong background and understanding of medications and formulary terminology
• Pharmacy technicians must be familiar with multiple Medicaid drug benefit design offerings and rules/regulations across multiple states. They must also be familiar with Medicare drug benefit design offerings that may differ by state, while being familiar with applicable federal rules/regulations that remain consistent throughout the nation

Skills

• Excellent computer skills such as working knowledge of Microsoft Outlook, Word, OnBase
• Excellent interpersonal, communication and attentive listening skills
• Strong organizational skills, detail oriented
• Demonstrated excellence in communication skills
• Demonstrated ability to work well with others
• Demonstrated ability to work in a fast paced, multi-task environment

Position Type:

Remote/Work from Home

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$19.66

Pay Range Maximum:

$27.42

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Why Choose Highmark Inc.?

As one of the nation"s leading health insurers, Highmark Inc. relies on a passionate team of over 5,000 people to make healthcare higher-quality, accessible, and affordable. We are known for how deeply we care-about our members and our employees. If you are looking to build a career with real purpose, you belong at Highmark.

Benefits & Perks

Taking Care of You

Your Benefits at a Glance

• Health: Complete medical, dental, vision, prescription, HSA, and FSA coverage.
• Time Off: Paid vacation, holidays, and dedicated volunteer time.
• Finance: Employer-sponsored 401(k), life/disability insurance, and tuition reimbursement.
• Perks: Exclusive team discounts on shopping, memberships, and events.

Medical Coverage

Medical, prescription drug, dental, and vision coverage

Paid Time Off

Vacation, holidays, volunteering

Retirement Package

Employer-sponsored 401(k) plan

Insurance & Coverage

Life, AD&D and disability insurance

Onsite & Preventative Care

We make staying healthy easy with 100% covered preventative exams (including flu shots) and onsite pharmacy services at major campuses. Plus, stay active with free fitness center access at major Highmark campuses, Allegheny General, and West Penn Hospital.

Make Mindful Changes

Secure bicycle parking at major campuses. Healthy food options at onsite cafeterias. Stress management classes including yoga, mindfulness, and meditation.

Holistic Support, 24/7

Work-life resources including assistance programs and financial counseling services. 24/7 telephone access to health and wellness coaching.

Get Rewarded for Giving Back

Health incentive program that rewards team members. Team member networks to gather in the name of health. Paid volunteer time and incentives for making a difference.

Hear from Our Team

Real people, real stories

"I have met some really great people over the years at Highmark Health and the company has treated me really well. I get really good benefits. I"ve always been rewarded for working hard. That"s what keeps me here."

Victoria T.

Associate Strategy Analyst, enGen

"I love participating with the PRIDE BRG. It"s an engaged, dynamic group of almost 400 people. I also love to turn on the digital hub on my computer and see what"s going on with any of the Business Resource Groups. It"s really neat to be able to support other BRGs and see others support PRIDE. Every time I go to a different BRG event, I always feel welcome, even if I"m not part of that group."

Amanda M.

Director of Social Determinants of Health | Vice Chair of PRIDE

Our Hiring Process: Step-by-Step

1. Apply

Find a role that sparks your passion and submit your application! We'll send an immediate confirmation email, and our team will review your qualifications over the next 1-2 weeks.

2. Interview

If your profile is a great match, we'll reach out to schedule your interview-whether by phone, video, or in person. Don"t worry, we'll provide all the prep details in advance so you can shine.

3. Job Offer

The moment you've been waiting for! If selected, we'll connect to celebrate and walk you through the details: compensation, benefits, paid time off, and all the perks of joining the team.

4. Pre-Employment

After you accept online, we'll guide you through standard screening (including a background check and drug screen, plus health screenings for certain clinical roles). Once cleared, we"ll officially confirm your start date!

5. Onboarding

Welcome aboard! Before Day 1, we'll send everything you need to hit the ground running-including your schedule, location, and the required identification documents to bring with you.

Bonus Fast-Track Tip

Applying for EVS, Dietary, or Customer Service roles? You can skip the traditional line and chat with Bridget, our AI recruiting assistant, to find open roles and schedule an eligible interview instantly.

Apply Now

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Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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