Pharmacy Medicare Coordinator

• Location 1300 EVERGREEN PARK DR SW,OLYMPIA, WA, ,United States
• Base Pay $ - $ / Year
• Job Category Pharmacy
• Employee Type Full Time Exempt
• Required Degree 4 Year Degree
• Manage Others No

The Pharmacy Medicare Coordinator is responsible for ensuring operational compliance, performance excellence, and regulatory adherence within the Medicare pharmacy benefit. This role provides second-line oversight of delegated and internal operational functions, monitors compliance with CMS requirements, and drives continuous improvement through audits, issue management, and performance monitoring.

This role will also play a key role in utilization management and quality programs by pulling and reviewing data from internal and external sources. In addition, this role will take the lead in operationalizing utilization management or quality programs including project management, communications and monitoring results.

The ideal candidate brings deep Medicare operational knowledge, strong regulatory acumen, and the ability to partner cross-functionally in a highly matrixed organization to mitigate risk and support high-quality member outcomes.

• Provide oversight of Medicare operational activities to ensure compliance with CMS regulations, contractual requirements, and internal policies.
• Monitor delegated and non-delegated Medicare functions, including claims, enrollment, appeals and grievances, utilization management, and pharmacy operations.
• Evaluate operational performance against CMS standards, KPIs, SLAs, and internal benchmarks.
• Support CMS program audits, data validation audits, mock audits, and readiness activities.
• Review and assess corrective action plans (CAPs) resulting from audits, compliance findings, or performance gaps.
• Partner with Compliance and Legal teams to interpret CMS guidance and ensure operational alignment with regulatory updates.
• Identify operational risks, trends, and systemic issues through data analysis, reporting, and oversight reviews.
• Identify utilization trends, and quality improvement opportunities through data analysis
• Run regular reports using SQL, Microsoft excel, Tuva and PBM claims systems
• Ensure timely escalation and resolution of compliance or operational concerns.
• Track remediation efforts and validate sustainable corrective actions.
• Conduct oversight reviews of delegated entities, including assessment of compliance, performance, and operational controls.
• Review delegated entity reports, audit results, and monitor outcomes.
• Collaborate with vendor management and business owners to address gaps and drive improvement.
• Develop and maintain dashboards, reports, and summaries for leadership related to Medicare operational performance and risk.
• Present findings, trends, and recommendations to senior leadership and governance committees.
• Support continuous improvement initiatives tied to Stars performance, member experience, and regulatory compliance.
• Serve as a subject matter expert for Medicare operational requirements.
• Partner with Operations, Compliance, Quality, Finance, and IT teams to support enterprise-wide initiatives.
• Contribute to policy and procedure development to ensure alignment with CMS requirements.
• Partner with sales and marketing to ensure member content is compliant and accurate.

• Medicare regulatory expertise
• Operational risk management
• Influencing without authority
• Continuous improvement mindset
• Strategic thinking and execution
• Regulatory and compliance awareness
• Cross-functional collaboration
• Stakeholder communication
• Risk management
• Attention to detail and quality
• Change management
  
  Data analytics, including SQL, Microsoft excel, tuva and PBM claims systems
• Project management
• Self-starter. Ability to set priorities and keep to projected schedules.

• Bachelor’s degree in healthcare administration, Business, Public Health, or a related field (or equivalent experience).
• 5+ years of managed care pharmacy operations experience (Enrollment/ Billing/ UM/ Claims/ etc.)
• 5+ years of pharmacy technician (CPhT) experience
• Strong working knowledge of CMS regulations, including 42 CFR, Medicare Managed Care Manual, and Part D guidance.
• Experience with PBM operational oversight, audit readiness, or second-line monitoring.
• Proven analytical, problem-solving, and risk assessment skills.
• Knowledge of Stars measures and their operational impact.
• Familiarity with healthcare data reporting and performance metrics.
• Strong written and…