Pharmacy Program Specialist II
: Job Details :

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

70% 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.

10% Override Requests and PBM Communication.

Manage and transmit override and approval decisions to external PBM partners to

ensure prompt access to medications.

10% 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

5% Reporting and Delegated Function Monitoring

Provide reporting and support to ensure the effectiveness of delegated PBM

activities.

5% 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.

Job Requirements:

Required

Education/Specialized Training/Licensure:

• Bachelor's degree in healthcare field, or in business administration. Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technician.

Work Experience (Years and Area): Minimum

• Three (3) years' experience with a Health Plan or PBM in related functions.
• Strong experience with prior drug authorization process in a Health Plan or PBM.

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

Visio is preferred.