Pharmacy Services Coordinator

Company: Highmark Inc. Job Description: Job Summary We are seeking a dedicated Pharmacy Services Coordinator to guide front line staff and ensure the efficient delivery of our Pharmacy call center services. In this pivotal role, you will be the first line of support, responding to physician and pharmacy network provider inquiries regarding medication requests, claims edits, and prior authorizations. Your expertise will help assess medical necessity for non-formulary requests and facilitate seamless communication with healthcare providers. Essential Responsibilities Engage with physicians and pharmacy network providers to address their needs promptly and courteously. Collaborate with staff to develop effective processes and solve problems. Manage inquiries about drug benefit design and effectively direct daily workflows. Prioritize requests for drug approvals and denials efficiently. Review prior authorization criteria for various drug products. Recommend staffing adjustments to maintain high efficiency and productivity levels. Ensure compliance with call center turnaround time requirements mandated by DPW/CMS regulations. Conduct thorough evaluations of non-formulary drug requests before processing approvals or overrides. Investigate member claim histories and suggest formulary alternatives as applicable. Communicate with physicians to gather any necessary additional information. Consult with staff clinical pharmacists for expert guidance when needed. Document all decisions on authorizations and denials accurately, adhering to state and federal regulations. Utilize the OnBase information system for documentation and Argus IPNS for authorization entries. Fulfill additional assigned duties effectively. Identify and report any issues with coordination of benefits through claims reviews. Represent the pharmacy department during onsite member appeals and grievance sessions. Serve as a technical resource for team members. Other duties as assigned. Qualifications: Minimum: High school diploma or GED. Experience in pharmacy prescription claims processing and payment. Preferred: Associate degree. Pharmacy technician certification. Background in managed care medication formulary management. Familiarity with retail pharmacy practices and third-party prescription processing. Strong knowledge of medications and formulary terminology. Understanding of Medicaid and Medicare drug benefit designs and regulations across various states. Skills: Proficient with Microsoft Outlook, Word, and OnBase. Exceptional interpersonal and communication abilities. Strong organizational skills with attention to detail. Ability to excel in a fast-paced, multi-tasking environment. Work Environment: No travel required. Disclaimer: This job description is intended to summarize the general nature and essential responsibilities of this position. It may not encompass all duties and qualifications required. Compliance Requirement: This role adheres to ethical standards and company policies regarding confidentiality and data security, including compliance with HIPAA regulations. The position requires a commitment to the company's Code of Business Conduct, including adherence to all applicable laws and regulations. Pay Range: Minimum: $19.01 Maximum: $24.19 Salary is based on various factors including qualifications, experience, and market considerations. Highmark Health prohibits discrimination based on veteran status or disability and follows all applicable federal, state, and local laws regarding equal employment opportunity. We strive for accessibility for all users. For accommodation requests, please reach out to HR Services. Req ID: J273822

Created: 2026-03-04