Pharmacy Specialist Level 1

This position is responsible for receiving and processing verbal and written prior authorization requests from pharmacists, physicians, and patients. The role supports the coordination of Pharmacy Services activities, including correspondence generation, reporting, and special projects. The position is expected to maintain performance standards in alignment with organizational goals and regulatory compliance requirements.

• Process prior authorization requests received through the prior authorization help line and fax submissions.
• Review documentation for accuracy, completeness, and medical necessity based on established drug-specific criteria.
• Submit cases for clinical review and determination.
• Interact directly with physician office staff, pharmacies, members, and internal stakeholders regarding eligibility, coverage determinations, and claims-related issues.
• Coordinate interventions with physician and pharmacy office staff to promote formulary compliance and generic medication utilization.
• Identify and recommend opportunities to improve departmental efficiency, accuracy, and productivity.
• Process ad hoc requests for information and reports from internal and external stakeholders.
• Participate in client, member, and employee training initiatives to support understanding of pharmacy services programs and operations.
• Assist with day-to-day pharmacy department operations and administrative functions.
• Support clinical programs and initiatives within the pharmacy department.

• National Pharmacy Certification preferred.
• Minimum of two (2) years of experience in third-party prescription claim adjudication required.
• Minimum of two (2) years of experience as a Pharmacy Technician required.
• Prior customer service and service quality improvement experience required.

• Strong attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Ability to work effectively with healthcare providers, pharmacies, members, and internal teams.
• Knowledge of pharmacy claims processing and prior authorization procedures.
• Ability to manage multiple tasks and meet productivity and quality standards.
• Strong problem-solving and customer service skills.
• Familiarity with healthcare regulations and compliance standards preferred.