JOB SUMMARY

Plays a crucial role in overseeing the day-to-day operational workflows surrounding physician-administered drugs (PADs) across all lines of business (Commercial, Medicare, and Medicaid). Working closely with the Pharmacy Supervisor, this individual is responsible for caseload management, case assignments, operational monitoring, and compliance oversight. The role serves as an internal subject matter expert and administrative backbone to ensure seamless execution, regulatory compliance (CMS, local regulations, and URAC standards), and high-quality service delivery.

ESSENTIAL FUNCTIONS

• Monitor daily operational activities across Medicaid, Commercial, and Medicare Advantage. 
• Caseload Review & Case Management Support:
  Workflow Tracking: Continuously review incoming and active caseloads for physician-administered drug pre-authorizations, claims reviews, and utilization management queues.
  Queue Balancing: Monitor real-time volume shifts across Commercial, Medicare, and Medicaid lines of business to prevent bottlenecks and backlogs.
  Complex Case Escalation: Identify high-risk or complex clinical cases and route them appropriately to clinical staff or supervisors while maintaining tracking protocols.
• Monitoring, Oversight & Reporting:
  Performance Metrics: Monitor operational dashboards, track key performance indicators (KPIs), and evaluate individual and team productivity.
  Support Supervisor and other areas on Regulatory Reporting: Generate routine and ad-hoc compliance, operational, and audit reports detailing processing volumes, approval/denial trends, and TAT compliance for executive review.
• Quality Assurance: Conduct regular internal audits of processed cases to verify accuracy, consistency, and alignment with operational and medical policy.
• Support supervisor with SOP development and maintenance: support or execute writing, updating, and maintaining Standard Operating Procedures (SOPs) for physician-administered drug workflows as medical policies change.
• Coordinate the preparation, processing, tracking, and distribution of pharmacy-related letters and correspondence for Physician administered Drugs. 
• Manage special letter projects, mass mailings, and line-of-business communication initiatives for Physician Administered Drugs.
• Cross-Functional Collaboration: Coordinate with Provider Relations, Claims, Pharmacy Benefits Management (PBM), and Clinical Teams to resolve operational roadblocks.
• Manage, execute and monitor special projects and initiatives that impact multiple lines of business.
• Assist in identifying operational gaps, workflow inefficiencies, and training needs; recommend process improvements to streamline PAD handling.
• Maintain organized documentation related to assigned Pharmacy processes. 
• Manage and execute updating procedures, workflows, templates, and operational documents.
• Ensure effective follow-up and follow-through of assigned activities, pending requests, and operational issues through completion.
• Perform any additional duties assigned by Supervisor or Manager.

EDUCATION

EXPERIENCE

Bachelor’s Degree, preferably in Business Administration or health related field and Pharmacy Technician Course. Three to five years of experience in office tasks, or equivalent experience in administrative roles.

LICENSES AND CERTIFICATIONS

COMPETENCIES