Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

* Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

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 

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.

Application Instructions

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