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Pharmacy Coverage Determination Jobs (NOW HIRING)

SlateRx

Clinical Coordinator

Las Vegas, NV · Remote

$23 - $26/hr

Experience in pharmacy benefit management, coverage determination, appeals and grievance (CDAG) operational processes, and regulatory requirements. * Computer and typing proficiency. * Ability to ...

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SlateRx

Clinical Coordinator

Las Vegas, NV · On-site +1

$23 - $26/hr

Experience in pharmacy benefit management, coverage determination, appeals and grievance (CDAG) operational processes, and regulatory requirements. * Computer and typing proficiency. * Ability to ...

New

Winston Staffing Services

Pharmacy Specialist

Newark, NJ · Remote

$19 - $20/hr

... Pharmacy Services activities including generating correspondence and special projects. Must ... for eligibility, coverage determination claims issues. - Conduct intervention with physician ...

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How much do pharmacy coverage determination jobs pay per hour?

As of Jun 11, 2026, the average hourly pay for pharmacy coverage determination in the United States is $19.27, according to ZipRecruiter salary data. Most workers in this role earn between $16.83 and $20.43 per hour, depending on experience, location, and employer.

What are some common challenges faced in a Pharmacy Coverage Determination role, and how can I prepare for them?

In a Pharmacy Coverage Determination role, professionals often encounter challenges such as interpreting complex insurance policies, staying updated with frequently changing formularies, and managing a high volume of prior authorization requests. Effective communication skills are essential, as you'll regularly interact with healthcare providers, patients, and insurance representatives to clarify coverage decisions. To prepare, it's helpful to familiarize yourself with insurance terminology, develop strong organizational habits, and stay current with relevant regulations and pharmaceutical guidelines.

What are the key skills and qualifications needed to thrive as a Pharmacy Coverage Determination Specialist, and why are they important?

To thrive as a Pharmacy Coverage Determination Specialist, you need a background in pharmacy or healthcare, knowledge of insurance processes, and typically a pharmacy technician certification or relevant experience. Familiarity with pharmacy benefit management (PBM) systems, electronic prior authorization software, and Medicare/Medicaid guidelines is essential. Strong attention to detail, problem-solving skills, and effective communication are critical soft skills for this role. These abilities ensure accurate coverage assessments, compliance with regulations, and positive patient and provider experiences.

What is the difference between Pharmacy Coverage Determination vs Pharmacy Benefits Manager?

AspectPharmacy Coverage DeterminationPharmacy Benefits Manager
RoleDecides whether specific medications are covered under insurance plansManages overall pharmacy benefits, including formulary design and claims processing
CredentialsPharmacists, pharmacy technicians, or healthcare professionalsPharmacists, healthcare administrators, or pharmacy benefit specialists
Work EnvironmentInsurance companies, healthcare providers, or pharmacy benefit departmentsInsurance companies, PBM companies, or healthcare organizations

Pharmacy Coverage Determination focuses on evaluating individual medication coverage requests, while Pharmacy Benefits Managers oversee the broader management of pharmacy benefits, including formulary development and claims processing. Both roles involve pharmacy expertise but differ in scope and responsibilities.

What is a Pharmacy Coverage Determination?

A Pharmacy Coverage Determination is a decision made by a health insurance plan about whether a prescribed medication is covered under a patient's pharmacy benefits. This process typically occurs when a patient or their healthcare provider requests coverage for a drug that is not automatically included on the plan's formulary, or when they seek an exception to standard coverage rules. Coverage determinations can involve approvals for non-formulary drugs, quantity limit exceptions, or prior authorizations. The outcome determines if the insurance will pay for the medication, and patients can appeal unfavorable decisions.
Infographic showing various Pharmacy Coverage Determination job openings in the United States as of June 2026, with employment types broken down into 11% Locum Tenens, 11% As Needed, 72% Full Time, 4% Part Time, and 2% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $40,074 per year, or $19.3 per hour.
Coverage Determination Representative

Coverage Determination Representative

BioPlus Specialty Pharmacy

Altamonte Springs, FL • On-site

Full-time

Medical, Retirement

Posted 5 days ago

Job description

Company Description
As one of the largest and most respected specialty pharmacies, BioPlus creates a meaningful difference to our patients, prescribers, payers, and pharmaceutical partners.
Our 2 - Hour Patient Acceptance Guarantee gives a quick response to prescribers and patients for critical, time - sensitive treatments. As we continue to grow, we need exceptionally talented, bright, and driven people. If you would like to help us continue to be the innovative leader in our industry, this is your chance to join our team.
Job Description
The Coverage Determination Rep I is responsible for gathering all information required on an authorization, completing, and submitting the authorization form to insurance company and for all follow up phone calls and documentation of these authorizations.
Responsibilities
  • Obtain prior authorizations; initiate requests, track progress, and expedite responses from insurance carriers and other payers.
  • Review prescription for accuracy of prescribed treatment regimen prior to submission of authorization.
  • Gather all necessary information from prescriber offices to complete authorization forms.
  • Notifying appropriate staff of approved/denied medications.
  • Process/reverse online claims to confirm authorization outcome.
  • Completes status check with insurance company regarding receipt and outcome of prior authorization.
  • Perform call to prescriber office for status of authorization or request for additional information.
  • Responsible for all documentation of authorization statuses into CPR+ progress notes.
  • Update sales staff with pertinent information.
  • Participate and perform other duties as assigned by leadership

Skills & Abilities
  • Positive Attitude
  • Professional appearance
  • Work cooperatively and be a liaison between departments when needed
  • Knowledge of standard medical terminology and pharmacy prior authorization and appeal/denial processes desired
  • Demonstrate excellent oral, presentation, and written communication skills
  • Demonstrate proficiency in the use of MS Office software, which includes Excel, Word, and Outlook
  • Demonstrate the BioPlus C.A.R.T. values.

Qualifications
  • High School Diploma or Equivalent.
  • At least 1 year experience working with pharmacy prior authorizations, or pharmacy billing.
  • Specialty pharmacy experience preferred.

Qualifications
Additional Information
BioPlus offers competitive compensation packages including health care, 401(k), growth potential, and a challenging and exciting work environment.
BioPlus is an Equal Opportunity Employer

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