Coordinator, Pharmacy Operations

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

Our Coordinator, Pharmacy Operations candidates can anticipate a role that plays a pivotal part in ensuring client satisfaction through the process of receiving and reviewing prescription and medical drug prior authorization (PA) requests from providers and members via telephone, fax, email, and web-enabled submissions. Candidates will provide value through efficient organization, communication, and documentation. Joining our team offers the satisfaction of contributing to an engaged team with a streamlined process and being a key link in our commitment to delivering exceptional service and better health outcomes.

Collaboration Opportunities:

• Coordinators will be working with and providing support to health plans, providers, Utilization Management support staff and Clinicians. Leadership rewards and regularly recognizes employees for performance in an environment that challenges while providing clear direction and support to foster success in the role.

What You’ll Be Doing:

• Navigate across multiple systems to respond to questions from external and/or internal partners.
• Consistently meet established productivity requirements, adherence to schedule and quality standards.
• Always maintain confidentiality of protected patient medical information.
• Ability to adapt to a changing environment, including scheduling flexibility.
• Perform ad-hoc projects to support pharmacy operation initiatives.
• Develop and maintain workflows and other training materials.
• Receive and review prescription prior authorization (PA) requests from providers and members via telephone, fax, email, and web-enabled submissions (e.g., electronic PA).
• Providing general prior authorization information via telephone, fax or email to providers, members and/or Evolent client partners.
• Perform outbound calls to provider and/or members to solicit information needed to process a prior authorization request, follow-up on PA requirements and/or provide consultation on the prior authorization program.
• Perform outbound notifications to members and/or providers notifying them of prior authorization outcomes.
• Review and approve, as applicable, member and provider inquiries for prior authorization requests based on established pharmacy guidelines and state and federal requirements.
• Perform quality review of prior authorization requests to ensure adherence of established pharmacy guidelines and state and federal requirements.
• Coordinate, compile and oversee the management of third-party external reviews for Medicare, Commercial and Medicaid lines of business.
• Process patient submitted Direct Member Reimbursement (DMR) claims and support the appeal and grievance process related to pharmacy clinical determinations.

Qualifications Required and Preferred:

• Available to work every other weekend - Required
• Available to work holidays on a rotation - Required
• Willingness to work any shift between 8am-7pm EST - Required
• Certified pharmacy technician (CPhT) - Preferred
• Associate or bachelor’s degree - Preferred
• Experience with MHK (formerly MedHOK) - Preferred
• Experience at a health plan or PBM - Preferred
• Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and ability to learn multiple work-related software applications - Preferred
• Ability to make independent decisions - Preferred
• Committed to team-oriented work environment - Preferred
• Exceptional interpersonal, presentation, oral and written communication skills - Preferred
• Strong work ethic built on a foundation of proactivity - Preferred
• Committed to the practice of inquiry and listening - Preferred
• Navigate ambiguity with structured problem-solving and decision-making - Preferred

Technical Requirements:

We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, speci