Specialty Rx Coordinator

Accountabilities: Prior Authorization Management: Collect and review pharmacy and medical records for prior authorization requests, helping manage increased workloads and ensuring requests are handled accurately and efficiently. Specialty Medication Coordination: Act as a liaison between retail and specialty pharmacies, prescribers, and members to document requests, communicate decisions, coordinate appeals, and address medication-related concerns. Single Case Agreements: Arrange and negotiate single case agreements, coordinate pricing, process claims accurately, update member records in the QicLink system, and provide ongoing agreement support. Member Financial Assistance: Assist members who express financial concerns about specialty medications and communicate escalated issues to the appropriate teams. Vendor Program Coordination: Submit referrals to third-party vendors responsible for specialty carve-out programs and serve as a liaison during program implementation and ongoing operations. Contract and Regulatory Compliance: Review existing and proposed vendor plan language to assess its impact under applicable governmental regulations, ensuring continued compliance with contractual requirements throughout the revenue cycle. Cross-Functional Collaboration: Work with customer service, plan administration, and other internal departments to develop and implement vendor-related policies and group plan language. Escalation Management: Coordinate vendor-related questions, resolve issues, and provide status updates to client executives, client service teams, and customer service representatives. Process Improvement: Collaborate with internal teams to improve communication, workflows, and service delivery between members, healthcare facilities, and vendors. Additional Responsibilities: Perform other duties as assigned to support medical management and specialty pharmacy operations. Requirements: Education: Bachelor's degree or equivalent professional work experience. Relevant Experience: At least five years of professional experience, including a strong understanding of pharmacy and medical benefits, specialty medications, J-codes and their administration, limited-distribution drugs, and specialty pharmacy manager selection. Prior Authorization Expertise: Previous experience managing pharmacy and/or medical prior authorization requests is required. Clinical and Medication Knowledge: Familiarity with medications used in rheumatoid arthritis (RA), transplantation, Hepatitis C, infectious diseases, and/or oncology is preferred. Communication Skills: Excellent written and verbal communication skills, with the ability to explain complex information clearly and coordinate effectively with members, providers, vendors, and internal teams. Organization and Attention to Detail: Strong organizational skills and a high level of accuracy when managing records, claims, agreements, and documentation. Time Management: Proven ability to meet deadlines, prioritize competing tasks, and manage responsibilities effectively in a fast-paced environment. Analytical and Problem-Solving Skills: Ability to evaluate information, identify issues, resolve problems, and support sound operational decisions. Adaptability and Initiative: Comfortable working under pressure, managing escalations, taking ownership of responsibilities, and collaborating with others to achieve results. Technical Proficiency: Proficiency with Microsoft Office Suite or comparable productivity software; familiarity with relevant claims or member management systems is beneficial. Core Competencies: Accountability, analytical thinking, collaboration, communication, customer focus, functional expertise, and initiative. Remote Work Requirements: Must have a reliable cable broadband or fiber-optic internet connection with minimum speeds of 100 Mbps download and 25 Mbps upload. Work Environment: Ability to perform standard desk-based duties involving extended periods of sitting and computer use. Benefits: Annual Salary: $50,000–$55,000, depending on qualifications, experience, and the hiring process. Medical Insurance: Access to medical coverage options. Dental and Vision Coverage: Dental and vision insurance to support overall health and well-being. Life and Disability Insurance: Coverage options designed to provide additional financial protection. Paid Time Off: Generous paid time off to support rest, personal needs, and work-life balance. Tuition Reimbursement: Financial support for eligible educational and professional development opportunities. Employee Assistance Program (EAP): Resources and support for personal and professional well-being. Technology Stipend: Financial assistance to support technology needs for remote work. Remote Flexibility: Fully remote work, offering the flexibility and comfort of working from home, subject to the required reliable internet connection.