Pharmacy Operations Coordinator
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Pharmacy Operations Coordinator overseeing PBM claims and formulary processes for American Health Plans. Supporting CMS compliance, Medicare reporting, audits, member eligibility, and plan operations.
Responsibilities:
- Serve as primary contact between the Plan and pharmacy benefit manager (PBM)
- Perform PBM oversight and monitoring
- Report and escalate performance deficiencies and status to management and the compliance department
- Review, conduct outreach, and track rejected pharmacy claims involving non-formulary, prior authorization (PA), Step Therapy (ST), and Quantity Limit (QL) requirements
- Ensure regulatory requirements are met for coverage determinations and redeterminations
- Lead annual readiness activities
- Liaise with the Enrollment Department to ensure appropriate member eligibility processing
- Support CMS Plan reporting, audits, monitoring activities, and submissions
- Assist with and track incoming calls from agents, pharmacies, nursing homes, providers/nurses, and members
- Coordinate monthly website updates
- Monitor and report departmental metrics
- Work on special projects and business initiatives as assigned
- Perform other duties as assigned
Requirements:
- High school diploma or equivalent required
- Pharmacy technician qualification/license/certification required
- Experience in the pharmacy department of a Medicare Advantage or Part D plan preferred
- Maintain regular and reliable attendance
- Attention to detail
- Ability to work in a high-demand, fast-paced environment
- Experience in planning and implementation
- Strong analytical skills
- Strong leadership and collaboration skills
- Extensive knowledge of Medicare compliance
- Customer and quality focus
- Follow up and resolve open items in a timely manner
- Adhere to all compliance requirements and CMS regulations
- Successfully complete required training
- Handle multiple priorities effectively
- Exercise independent discretion and decision-making
- Make decisions under pressure
Similar Jobs
Operations Analyst
Operations Analyst improving residential program tools, reporting, and processes. Developing Excel solutions, managing project timelines, and supporting change rollouts.
Insurance Operations Specialist
Insurance Operations Specialist improving agency workflows and platform adoption for Outmarket, an AI-powered commercial insurance platform. Partnering with clients and CSMs on training, enablement, issue triage, onboarding, renewals, and expansion.
Regional Operations Manager
Regional Operations Manager overseeing HVAC wholesale branches across sales, customer service, staffing, inventory, and profitability. Coaching Branch Managers and coordinating operations, HR, sales, and corporate teams.
Senior Operations Coordinator – 3rd Party Logistics
Senior Operations Coordinator supporting third-party logistics client accounts, fulfillment, reporting, and order processing remotely. Improving operational workflows and coordinating projects across client services and operations teams.
Commercial Operations Manager
Commercial Operations Manager strengthening reporting, CRM, forecasting, and governance for Dayshape’s AI-powered resource management platform. Driving cross-functional revenue operations across Sales, Customer Success, Marketing, Finance, and leadership.
D365 Operations Lead
D365 Operations Lead supporting ERP, supply chain, and logistics systems for a software development client in India. Navigating integrations, troubleshooting systems, and supporting AI-driven automation capabilities.
Operations Manager, Concierge
Gestionnaire indépendant optimisant les locations courte durée d’ALB Conciergerie, réseau français de gestion immobilière. Gérant annonces, réservations, tarification et propriétaires pour bâtir un portefeuille générant des commissions récurrentes.
Airbnb Operations Manager
Responsable indépendant gérant et optimisant des locations courte durée pour ALB Conciergerie, réseau français de conciergerie immobilière. Développement d'un portefeuille de propriétaires et coordination des séjours.
Market Operations Associate
Market Operations Associate optimizing driver supply and NEMT trip execution for Wingz, a US rideshare company. Managing dispatch, onboarding, routing, and on-time performance across Latin American markets.
Recruitment Operations Manager
Recruitment Operations Manager leading recruiter teams and ATS workflows for Hire Hangar, which connects talent with vetted employers. Improving staffing processes, metrics, and client service remotely.
Operations & User Growth
Earn operations and growth specialist driving crypto product adoption at Binance. Executing campaigns, token partnerships, performance analysis, and institutional client onboarding across Asia.
CRM Operations Analyst – Mid-level
Analista de CRM monitorando jornadas de WhatsApp, leads e capacidade comercial na edtech Fluency. Construindo relatórios, investigando incidentes e apoiando decisões rápidas com dados operacionais.
Foundational Data Resources Analyst – North America Sales Operations
Foundational Data Resources Analyst optimizing sales forecasting, analytics, and revenue operations for Hewlett Packard Enterprise’s edge-to-cloud technology business. Supporting North America sales teams with process and tool improvements.
Operations Coordinator
Operations Coordinator keeping a UK company’s workflows, projects, data, and processes on track. Managing SOPs, reporting, scheduling, and cross-department follow-through remotely from South Africa.
Customer Operations Specialist – B2B SaaS
Customer Operations Specialist responsible for B2B partner onboarding and operational support. Collaborating with customers and cross-functional teams to ensure efficient processes and product feedback.
Director of Insurance Operations
Insurance Operations Director leading US insurance teams and national broker partnerships for Odevo, a technology-enabled residential property management company. Owning delivery processes, reporting, growth, and operational improvement.
Director, Community Care Operations
Director overseeing virtual behavioral healthcare operations for Array Behavioral Care, a telepsychiatry and therapy provider. Managing partners, budgets, P&L, clinician capacity, and cross-functional service delivery.
Assistant Quality Process Manager
Assistant Quality Process Manager improving quality processes for BUILD Renewables, a utility-scale solar and battery-storage EPC company. Auditing projects, guiding teams, analyzing root causes, and driving standardized execution nationwide.
Fundraising Operations Coordinator
Fundraising operations coordinator supporting NPR and PBS public media stations through Salesforce and RevCRM. Managing donor issues, pledge drives, membership benefits, and fundraising data.
Operations Coordinator
Operations Coordinator supporting HR, compliance, finance, and IT workflows at WattTime, an environmental tech nonprofit. Coordinating distributed-team operations and employee processes.