Pharmacy Care Coordinator

Children’s Hospital of Philadelphia•Philadelphia, PA

20d•$26 - $32

About The Position

The Pharmacy Care Coordinator (PCC) ensures timely patient access to medication therapies by managing benefit verification, prior authorizations, reauthorizations, and appeals. The role handles inbound calls, which may include serving as a call center resource, triages inquiries, explains benefits structures and copay assistance programs, and resolves complex coverage barriers. The PCC partners with patients, providers and clinic staff, payors, and internal and external pharmacies, and accurately documents activity in the electronic health record through final authorization determination. The coordinator helps determine pharmacy eligibility, coverage status, restrictions, dispensing options, and next steps; submits and tracks authorization requests and appeals; communicates coverage and authorization information; and coordinates referrals to CHOP or external pharmacies. The role follows organizational policies, payor contracts, and regulatory requirements and participates in departmental quality assurance and improvement initiatives.

Requirements

High School Diploma or GED.
At least two years of relevant job experience.
Ability to work with stressful situations.
Strong interpersonal, written, and verbal communication skills, including professional, high-quality customer service to patients, families, providers, payers, and clinical staff in person and by phone.
Ability to work efficiently and professionally with minimal supervision in a fast-paced, metrics-driven environment.
Proficiency with computers and Microsoft 365 applications, and ability to learn and apply new systems, tools, and procedures quickly.
Ability to manage multiple cases simultaneously, prioritize workload, adapt to changing departmental needs, support team members, and adjust assignments as needed.
Knowledge of commercial, Medicaid, and Medicare insurance plans, including program requirements and coverage processes.
Ability to demonstrate CHOP ICARE values: Integrity, Compassion, Accountability, Respect, and Excellence, including compassion and empathy when supporting patients and families.
Strong organizational skills, critical thinking, and attention to detail; ability to solve problems, make informed decisions, and ensure accurate documentation and data entry in compliance with payer requirements.
Proficiency using electronic health records and pharmacy systems, such as Epic Hyperspace, Epic Willow, HDMS, or similar.
Experience using payer and insurance websites and tools, such as NaviNet, WebMD, Passport, Availity, CoverMyMeds, Surescripts, PromptPA, PEAR Portal, or similar.
Working knowledge of common medical terminology, abbreviations, and basic pharmacy calculations.
Employees working in patient care buildings or with patient-facing responsibilities must receive an annual influenza vaccine as a condition of employment.

Nice To Haves

Bachelor's degree preferred.

Responsibilities

Verify pharmacy and/or medical benefits using third-party benefit coverage and authorization vendors to determine pharmacy eligibility and the appropriate dispensing pharmacy.
Perform billing and/or claim adjudication; identify coverage status, payor restrictions, servicing pharmacy options, and appropriate next steps for issues such as prior authorization, benefits investigation, step therapy, non-formulary coverage, financial assistance, and copay-assistance programs.
Submit, track, and follow up on prior authorizations, reauthorizations, and appeals according to payor-specific requirements.
Follow up with insurance companies, providers and clinic staff, and patients or families about therapies identified as ineligible or non-covered.
Contact provider and clinic staff with information requiring follow-up.
Answer inbound calls, which may include serving as a call center resource, and triage patient, provider, and payor inquiries to appropriate teams.
Coordinate with provider and clinic staff, pharmacies, and payors to support continuity of care and timely access to therapy.
Clearly communicate authorization status, coverage limitations, outstanding financial obligations when appropriate, and next steps to patients, families, and providers or clinic staff.
Accurately document activities, communications, and determinations in the EHR.
Refer eligible patients to CHOP’s comprehensive pharmacy program, including retail, specialty, and home infusion pharmacies; identify cases requiring external pharmacy referral and notify provider or clinic staff using established documentation and communication standards.
Adhere to organizational policies, payor contracts, and regulatory requirements.
Participate in departmental quality assurance and improvement initiatives.
Perform other duties as assigned by management.