Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY:
The Pharmacy Program Specialist II performs criteria-based review of pharmacy and medical benefit requests in accordance with established clinical guidelines, plan policies, and prior authorization protocols. The role requires a strong understanding of pharmacy and medical benefit drug coverage, and adherence to regulatory timelines. The specialist also contributes to reporting, monitoring delegated PBM functions, and promoting member adherence, while delivering a high level of customer service.
The position does not exercise independent clinical judgment or make final adverse determinations, and all requests requiring clinical discretion are routed to a licensed pharmacist or appropriate clinical reviewer.
JOB SPECIFICATIONS AND CORE COMPETENCIES:
Prior Authorization and Criteria-Based Review
Process prior authorization requests according to established criteria and protocol within defined turnaround time standards
Review pharmacy and medical benefit requests against established clinical criteria, plan policies, and authorization guidelines
Ensure completeness and accuracy of submitted documentation prior to escalation
Route requests that require clinical judgment or exception review to a licensed pharmacist or appropriate clinical reviewer
Identify and escalate incomplete, non-compliant, or exception-based requests to appropriate clinical reviewer
PBM Coordination and Workflow Support
Coordinate with PBM and internal departments to support authorization workflows
Track request status and ensure adherence to service level requirements
Communicate and effectuate request outcomes based on established determinations and protocol
Reporting and Monitoring Support
Support tracking of prior authorization volumes, turnaround times, and workflow performance
Assist in monitoring delegated functions and identifying operational variances
Maintain documentation to support audit readiness and compliance requirements
Other duties as assigned.
QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's degree in healthcare field, or in business administration required.
Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technician required.
Work Experience (Years and Area):
Minimum Three (3) years' experience with a Health Plan or PBM in related functions.
Strong experience with prior drug authorization process in a Health Plan or PBM
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point)
Visio preferred.
Other: Clinical Decision Authority Limitation:
This position performs criteria-based review functions only. The role does not independently override established criteria or render adverse clinical determinations.
COMPETENCIES:
Problem Analysis
Results Oriented
Attention to Detail
Leadership
List any additional competencies:
Technical Competencies
Ability to accurately apply predefined clinical criteria and guidelines
Strong understanding of prior authorization workflows and escalation protocols
Knowledge of PBM processes and delegated function structures
Analytical and Process Skills
Attention to detail in criteria-based review and documentation validation
Ability to identify when a request falls outside established criteria
Compliance and Risk Awareness
Understanding of scope-of-role limitations
Ability to appropriately escalate clinical decisions to licensed pharmacist or appropriate clinical reviewer
INTERPERSONAL SKILLS
Ability to explain and communicate complex ideas with a diverse population
