Sr. Pharmacy Operations Coordinator

UPMC Health Plan has an exciting opportunity for a Sr. Pharmacy Operations Coordinator position in the Pharmacy Services department. This is a full-time hybrid position based in the Pittsburgh area. While you'll primarily work remotely, you'll come into the office occasionally depending on departmental needs.

Oversees operational and system processes as they relate to pharmacy benefits, implementation, training and maintenance for all UPMC product lines. Provide expertise in health plan and PBM system interfaces, eligibility exchanges, claims processing, accumulators, and data integration requirements to evaluate PBM capabilities. This position is responsible for conducting operational surveillance, vendor oversight, reporting requirements as well as the creation and implementation of new business processes. Must possess analytical problem-solving skills, coordinate the work of others and communicate effectively with all levels of management. Work is assigned through the AVP of Pharmacy Operations.

Responsibilities:

• Lead operational workstream, associated with the PBM RFP, implementation and transition activities, including vendor assessment.
• Ensure operational requirements are fully reflected in vendor proposals and contractual commitments
• Coordinate prior authorization workflows, clinical program implementation, and utilization management processes across internal clinical teams and the PBM, specifically the new vendor integration with medical claims processing system and existing PA vendor (Agadia) if applicable and ancillary vendor relationships (Greenback Health, Free Market Health, PillarRx).
• Ensure operational compliance with CMS, state Medicaid, Medicare Advantage, Commercial, and Exchange regulatory requirements, including readiness for evolving PBM transparency and oversight regulations.
• Supporting pharmacy network changes, member disruption mitigation, communication planning, and implementation readiness activities.
• Developing and monitoring PBM service level agreements (SLAs), operational performance guarantees, and corrective action plans.
• Responsible for data compilation, project tracking and report creation.
• Design, update and maintain pharmacy operational policies and procedures. Document work flows as needed. Identifies training and development needs of pharmacy staff.
• Work with internal teams to review and evaluate operational processes to gain efficiencies and ensure appropriate clinical or regulatory standards are being met.
• Create ad hoc reports and perform data analysis on call trends, clinical review activities, pharmacy claims, overrides and rejections to identify opportunities to increase efficiencies within the department.
• Collaborate with Pharmacy clinical staff on benefit configuration and clinical initiatives for our members and providers.
• Lead meetings or represent the Pharmacy operations in meetings with internal departments, clients or regulatory agencies as needed.
• Lead implementation projects with pharmacy department vendors to enhance pharmacy operations and implement regulatory requirements for the UPMC Health Plan and TPA clients,
• Serves as a point person within the Pharmacy Operations area for internal and external stakeholders such as the Pharmacy Benefit Manager, new vendors, quality departments and IT as it relates to pharmacy operations.