State of Washington
Pharmacy Authorization Specialist (HCPS/CQCT)
State of Washington, Walla Walla, Washington, United States
Overview
Pharmacy Authorization Specialist (HCPS/CQCT) This position works to resolve issues that arise for Apple Health clients attempting to access prescribed medication. This specialist uses adept critical thinking skills to determine the issue and work towards a resolution, including interpreting rejection codes, understanding how claims for drugs are billed, and communicating with stakeholders including clients and providers. This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. HCA has currently suspended the ability to support out-of-state telework. Responsibilities
Ensures timely review of authorization requests for prescription drugs and identifies opportunities to increase 1st level review by authorization staff. Ensures timely resolution of access issues related to prescription drug authorizations. This includes tracking, monitoring, and resolving authorization issues across all Apple Health Managed Care and fee-for-service (FFS) pharmacy programs. Communicates resolution to impacted providers and clients. Provides oral and written guidance to the Pharmacy Authorization unit in response to policy questions. Creates, updates, and reviews documents used by the Pharmacy Authorization unit. Researches and resolves pharmacy claim processing system issues relating to pharmacy authorizations. This includes performing system testing to investigate, identify, and resolve processing errors. Performs regular QC/QA of Pharmacy Authorization work to determine accuracy of the application of clinical policy. Coordinate implementation of clinical policies, new prior authorization initiatives, and updates to the Apple Health Preferred Drug List (AHPDL). Designs, develops, monitors and analyzes drug authorization determination reports. Qualifications
Required qualifications:
Qualifying candidates will have two (2) years of claims processing, billing, authorization, or analysis in an NCPDP compliant Pharmacy Point of Service claims processing system, HCA’s ProviderOne MMIS system, or comparable medical claim management system. Qualifying candidates will also satisfy one of the following criteria options: Option 1
Master’s degree with major study in public health, public administration, social work, or closely related field and two (2) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 2
Bachelor’s degree with major study in public health, public administration, social work, or closely related field and four (4) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 3
Associate degree with major study in public health, public administration, social work, or closely related field and six (6) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 4
Eight (8) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 5
One (1) year as a Health Care Program Consultant in state service. Preferred Qualifications Knowledge of pharmacy industry and prescription drug terminology; Knowledge of and experience with current NCPDP transactional standards; Knowledge of and experience with Excel, Word, and Decision Support applications; Knowledge of Federal and state laws and regulations, related to Medicaid and health care, with particular emphasis in the optional provision of pharmacy benefits within Medicaid according to section 1927 of the SSA; Knowledge of continuous quality improvement practices; Knowledge of methods of practice of research, analysis, and report writing at an independent level. How To Apply
Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files: A cover letter that specifically addresses how you meet the qualifications for this position Current resume To take advantage of veteran preference, please do the following: Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter. Please black out any PII data such as social security numbers. Include your name as it appears on your application in careers.wa.gov. About HCA
Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible. There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents. What We Have To Offer includes meaningful work with friendly co-workers who care about those we serve; Voices of HCA; a clear agency mission that drives our work and is person-centered; a healthy work/life balance, including alternative/flexible schedules and mobile work options; a great total compensation and benefit package; free parking; and a safe, pleasant workplace in a convenient location with restaurants and shopping nearby. Notes
Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment. HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. If you have any questions about the required qualifications or how your experience relates to them, please contact us at HCAjobs@hca.wa.gov. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Jake Nelko at jake.nelko@hca.wa.gov or 360.725.0945. The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply. E-Verify® is a registered trademark of the U.S. Department of Homeland Security. Subscribe to our weekly newsletter to receive a list of new job postings at HCA. More than Just a Paycheck! Employee benefits are not just about the kind of services you get, they are also about how much you may have to pay out of pocket. Washington State offers one of the most competitive benefits packages in the nation. Read About Our Benefits. The following information describes typical benefits available for full-time employees who are expected to work more than six months. Actual benefits may vary by appointment type or be prorated for other than full-time work. Please visit the State HR Website for more detailed information regarding benefits. Note: If the position offers benefits which differ from the following, the job posting should include the specific benefits. Insurance Benefits include medical (including vision), dental and basic life insurance, flexible spending accounts, and other coverages. Retirement and Deferred Compensation details, Public Service Loan Forgiveness, holidays, sick leave, vacation, and military leave information are also described. For full details, please view the job posting. Updated 07-21-2025 Additional Questions (Sample)
01. Please select the highest level of education completed: High school graduation or equivalent Associate degree Bachelor's degree Master's degree or higher None of the above 02. Which describes your experience with claims processing, billing, authorization, or analysis in an NCPDP compliant system? I do not have this experience. Less than 1 year More than 1 year, but less than 2 years More than 2 years 03. Supervisory or consultative experience in health services, social services, or Medicaid programs? I do not have this experience Less than 2 years More than 2 years, but less than 4 years More than 4 years, but less than 6 years More than 6 years, but less than 8 years More than 8 years Notes: This description retains the essential job information while removing irrelevant UI and formatting issues.
#J-18808-Ljbffr
Pharmacy Authorization Specialist (HCPS/CQCT) This position works to resolve issues that arise for Apple Health clients attempting to access prescribed medication. This specialist uses adept critical thinking skills to determine the issue and work towards a resolution, including interpreting rejection codes, understanding how claims for drugs are billed, and communicating with stakeholders including clients and providers. This position is eligible to telework and is typically not required to report on-site. The default assigned work location of all Health Care Authority (HCA) positions – both on-site and telework eligible positions – is within the State of Washington. This position reports to Olympia, WA. Frequency of onsite work will vary based on business and operational needs. HCA has currently suspended the ability to support out-of-state telework. Responsibilities
Ensures timely review of authorization requests for prescription drugs and identifies opportunities to increase 1st level review by authorization staff. Ensures timely resolution of access issues related to prescription drug authorizations. This includes tracking, monitoring, and resolving authorization issues across all Apple Health Managed Care and fee-for-service (FFS) pharmacy programs. Communicates resolution to impacted providers and clients. Provides oral and written guidance to the Pharmacy Authorization unit in response to policy questions. Creates, updates, and reviews documents used by the Pharmacy Authorization unit. Researches and resolves pharmacy claim processing system issues relating to pharmacy authorizations. This includes performing system testing to investigate, identify, and resolve processing errors. Performs regular QC/QA of Pharmacy Authorization work to determine accuracy of the application of clinical policy. Coordinate implementation of clinical policies, new prior authorization initiatives, and updates to the Apple Health Preferred Drug List (AHPDL). Designs, develops, monitors and analyzes drug authorization determination reports. Qualifications
Required qualifications:
Qualifying candidates will have two (2) years of claims processing, billing, authorization, or analysis in an NCPDP compliant Pharmacy Point of Service claims processing system, HCA’s ProviderOne MMIS system, or comparable medical claim management system. Qualifying candidates will also satisfy one of the following criteria options: Option 1
Master’s degree with major study in public health, public administration, social work, or closely related field and two (2) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 2
Bachelor’s degree with major study in public health, public administration, social work, or closely related field and four (4) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 3
Associate degree with major study in public health, public administration, social work, or closely related field and six (6) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 4
Eight (8) years of supervisory or consultative experience in health services, social services, or Medicaid programs. Option 5
One (1) year as a Health Care Program Consultant in state service. Preferred Qualifications Knowledge of pharmacy industry and prescription drug terminology; Knowledge of and experience with current NCPDP transactional standards; Knowledge of and experience with Excel, Word, and Decision Support applications; Knowledge of Federal and state laws and regulations, related to Medicaid and health care, with particular emphasis in the optional provision of pharmacy benefits within Medicaid according to section 1927 of the SSA; Knowledge of continuous quality improvement practices; Knowledge of methods of practice of research, analysis, and report writing at an independent level. How To Apply
Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files: A cover letter that specifically addresses how you meet the qualifications for this position Current resume To take advantage of veteran preference, please do the following: Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter. Please black out any PII data such as social security numbers. Include your name as it appears on your application in careers.wa.gov. About HCA
Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible. There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents. What We Have To Offer includes meaningful work with friendly co-workers who care about those we serve; Voices of HCA; a clear agency mission that drives our work and is person-centered; a healthy work/life balance, including alternative/flexible schedules and mobile work options; a great total compensation and benefit package; free parking; and a safe, pleasant workplace in a convenient location with restaurants and shopping nearby. Notes
Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment. HCA is an equal opportunity employer. We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA’s mission. Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. If you have any questions about the required qualifications or how your experience relates to them, please contact us at HCAjobs@hca.wa.gov. Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Jake Nelko at jake.nelko@hca.wa.gov or 360.725.0945. The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply. E-Verify® is a registered trademark of the U.S. Department of Homeland Security. Subscribe to our weekly newsletter to receive a list of new job postings at HCA. More than Just a Paycheck! Employee benefits are not just about the kind of services you get, they are also about how much you may have to pay out of pocket. Washington State offers one of the most competitive benefits packages in the nation. Read About Our Benefits. The following information describes typical benefits available for full-time employees who are expected to work more than six months. Actual benefits may vary by appointment type or be prorated for other than full-time work. Please visit the State HR Website for more detailed information regarding benefits. Note: If the position offers benefits which differ from the following, the job posting should include the specific benefits. Insurance Benefits include medical (including vision), dental and basic life insurance, flexible spending accounts, and other coverages. Retirement and Deferred Compensation details, Public Service Loan Forgiveness, holidays, sick leave, vacation, and military leave information are also described. For full details, please view the job posting. Updated 07-21-2025 Additional Questions (Sample)
01. Please select the highest level of education completed: High school graduation or equivalent Associate degree Bachelor's degree Master's degree or higher None of the above 02. Which describes your experience with claims processing, billing, authorization, or analysis in an NCPDP compliant system? I do not have this experience. Less than 1 year More than 1 year, but less than 2 years More than 2 years 03. Supervisory or consultative experience in health services, social services, or Medicaid programs? I do not have this experience Less than 2 years More than 2 years, but less than 4 years More than 4 years, but less than 6 years More than 6 years, but less than 8 years More than 8 years Notes: This description retains the essential job information while removing irrelevant UI and formatting issues.
#J-18808-Ljbffr