Pharmacy Prior Authorization Coordinator I
About The Position
Sentara Health Plans is looking to hire a Pharmacy Prior Authorization Coordinator 1. This is a remote position available in multiple states. The role involves delivering high-quality customer service by managing calls from members, provider offices, and pharmacies. The primary responsibility is supporting the processing of prior authorization (PA) requests for pharmacy benefit medications, ensuring accuracy, compliance with regulatory and clinical guidelines, and alignment with client performance standards. The Coordinator I works under general supervision, utilizing established protocols and systems for timely, efficient, and accurate PA determinations. This role requires the use of various business systems and tools to retrieve information, analyze requests, and enter PA data for claims adjudication. The Coordinator I must apply reasoning skills to identify incomplete information and determine appropriate actions based on client-specific criteria and clinical protocols. Interaction with internal teams and external stakeholders is regular to ensure consistent, high-quality service delivery. Work is guided by documented procedures, training, and prior experience.
Requirements
- 1 year healthcare experience required.
- High School Diploma or GED strongly preferred.
Responsibilities
- Verify member insurance eligibility and pharmacy benefit coverage.
- Communicate with members and providers regarding basic pharmacy inquiries and PA status.
- Accurately enter and process prior authorization (PA) requests into the system, prioritizing appropriately.
- Ensure PA requests are processed and finalized within required turnaround times (TAT) and client Performance Guarantees (PGs), using provided clinical guidelines.
- Review medication history and assess for formulary alternatives and “tried and failed” drugs.
- Document all relevant PA information clearly and accurately, including approval or denial rationale.
- Send PA status updates to providers and pharmacies via fax or other required methods.
- Adhere to defined roles and responsibilities related to clinical decision-making boundaries.
- Meet or exceed productivity and accuracy targets for PA processing.
- Coordinate with members, providers, and pharmacies to obtain missing information or clarification.
- Make outbound calls to gather additional information or respond to inquiries related to PAs, clinical programs, or claim adjudication.
- Collaborate with Pharmacy Concierge teams to resolve questions or issues related to PA processing or pharmacy benefits.
- Maintain strict confidentiality and security of all member and PA-related data, following applicable protocols for data handling and storage.
- Other duties may be assigned.
Benefits
- Medical, Dental, Vision plans
- Adoption, Fertility and Surrogacy Reimbursement up to $10,000
- Paid Time Off and Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term, Short-Term Disability, and Critical Illness plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
- Student Debt Pay Down – $10,000
- Pet Insurance
- Legal Resources Plan
- Annual discretionary bonus opportunity
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
