JOB SUMMARY
Under the direction of the Manager, Managed Care Pharmacy Operation, the Pharmacy Program Specialist II supports the operational needs of the pharmacy team by managing prior authorization processes, coordinating communication between members and providers, and addressing issues with the Pharmacy Benefit Manager (PBM). The role requires a strong understanding of medical benefit drug coverage and adherence to regulatory timelines. The specialist also contributes to reporting, monitoring delegated PBM functions, and promoting member adherence, while delivering a high level of customer service.


JOB SPECIFICATIONS AND CORE COMPETENCIES
Medical Benefit Prior Authorizations and Pharmacy Benefit Support
Process prior authorization requests for drugs under the medical benefit.
Respond to inquiries regarding pharmacy benefits, and medical drug benefits
Resolve issues with PBM regarding drug coverage, copays, prior authorizations, and appeals
Ensure all authorization and appeal requests are processed within required turnaround times.
Override Requests and PBM Communication
Manage and transmit override and approval decisions to external PBM partners to ensure prompt access to medications.
Member and Provider Outreach & Adherence Support
Make outreach to members and providers as directed to resolve issues with medical requests within required turn-around time. Make outreach to members and providers as directed to improve medication adherence
Reporting and Delegated Function Monitoring
Provide reporting and support to ensure the effectiveness of delegated PBM activities.
Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plan, and other duties as assigned.

Reports to Position Title:Manager, Managed Care Pharmacy Operation

QUALIFICATIONS:
Education/Specialized Training/Licensure:Bachelor's degree in healthcare field, or in business administration required.

Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technician required.

Work Experience (Years and Area):Minimum Three (3) years' experience with a Health Plan or PBM in related functions required.

Strong experience with prior drug authorization process in a Health Plan or PBM
Management Experience (Years and Area):N/A

Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point)

Visio preferred.

Job Family/Job Title Competencies
Problem Analysis
Results Oriented
Attention to Detail
Leadership

INTERPERSONAL SKILLS
Ability to explain and communicate complex ideas with a diverse population.