Pharmacy Coordinator (Appeals)

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 (Appeals) - Florida

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

• Performs other duties as assigned

• Complies with all policies and standards

For Centene Pharmacy Services:

Education / Experience: High school diploma or equivalent. 3+ years of pharmacy experience required, preferably in a managed care environment. Medicare and/or Medicaid experience preferred. 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.
 

License/Certificate: Current state's Pharmacy Technician license preferred. (Florida). Nationally Certified Pharmacy Technician PTCB or ExCPT, highly preferred

Location: Remote Florida only - Must live in the state of Florida
 

Schedule / Working shift: Open flexibility required - Full-time / 40 hours - 5 days/week. Need to be available anytime from Sunday-Saturday from 8:00AM – 7:00PM (EST). Schedule will include at least 1 shift on the weekend (Saturday or Sunday) per week. Shifts will be determined after the candidate is hired, based on business need.

Job specific responsibilities:​

• Pharmacy Grievances, Appeals, and Prior Authorizations

• Processing Pharmacy Appeals from Medicaid and Ambetter LOBs (Sunshine Health/FL Marketplace)

• Place outbound calls to inform member/provider of pharmacy appeal determination

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

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.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act