340B Program Coordinator

Reports To: Pharmacy Business and 340B Coordinator Manager

Employee Type:              EXEMPT              X    NON-EXEMPT

POSITION SUMMARY:

The 340B Program Auditor ensures compliance, accuracy, and integrity across all aspects of Mayers Memorial Healthcare District’s 340B Drug Pricing Program. This position performs scheduled and comprehensive audits of the entity’s 340B operations — including the entity-owned retail pharmacy and contract pharmacy partnerships — to verify adherence with HRSA, OPAIS, and organizational policy requirements. 

The Auditor serves as the internal compliance lead for self-audits, reconciliations, and ongoing monitoring, maintaining a continuous state of audit readiness while promoting transparency, accuracy, and sustainability of the 340B Program. 

This position may also assist with pharmacy operational activities related to the 340B Program, including report development, retail pharmacy inventory management support, contract pharmacy coordination, and support of new 340B partnerships or service line expansions as program needs evolve.

This job description is intended to identify some of the primary duties and responsibilities.  Mayers Memorial Hospital District reserves the right to modify, supplement, delete or augment the duties and responsibilities specified in this position description, at MAYERS MEMORIAL HOSPITAL DISTRICT’S sole and absolute discretion.

POSITION QUALIFICATIONS:

1. High school diploma or equivalent. 
2. Foundational knowledge of pharmacy operations and terminology. 
3. Proficient in Microsoft Excel. 
4. Willingness to learn 340B management platforms. 
5. Strong attention to detail and confidentiality. 
6. Excellent written and verbal communication skills. 
7. Completion of Apexus 340B University or equivalent training within three (3) months of hire.

PREFERRED QUALIFICATIONS:

1. Three (3) years of experience in healthcare, pharmacy, or related field. 
2. National Pharmacy Technician Certification (CPhT). 
3. Experience with the 340B Drug Pricing Program. 
4. Hospital or retail pharmacy experience. 
5. Apexus Advanced 340B Operations Certificate.

SCHEDULE AND EXPECTATIONS:

1. Performs structured audits weekly, monthly, and quarterly. 
2. Travel may be required between covered entity and contract pharmacy locations. 
3. Ensures consistent documentation and timely submission of audit results. 
4. Supports the 340B Coordinator in maintaining HRSA audit readiness. 

POSITION RESPONSIBILITIES:

General Competencies:

1. Professional behavior is demonstrated, both when on duty and as a representative of MMHD outside of normal work hours.
2. Ability to work with others, at all levels within the organization, and collaborate effectively.
3. Above-average interpersonal, problem-solving, and written and oral communication skills.
4. A positive working relationship with patients, visitors, and facility staff is demonstrated.
5. Organizational ability and time management is demonstrated.
6. Produces deliverable products on time, within budget with minimal direction.
7. Demonstrates the ability to compile and organize data using Microsoft Office Applications.  Ability to make appropriate recommendations or conclusions, given the data obtained.
8. Maintains an organized set of records, upon request, for the functions that are performed within the scope of this job.
9. Communicates appropriately and clearly to directors, managers, and coworkers.
10. Performs all assigned tasks accurately, to include proper spelling and grammar, reference materials, and minimal mathematical calculation.
11. Takes direction from others to include those employees of other departments with which he/she works on a temporary basis in accordance with the chain of command.
12. Maintains all information as confidential as appropriate, to include payroll, material produced for union negotiations, personnel information, and other information obtained during the course of performing job duties that is confidential.
13. Demonstrates ability to effectively use office machines in the performance of job functions.
14. Answers phone calls, assists public, and forwards appropriately if necessary and in a professional and friendly manner.
15. Other duties as assigned.

Specific Competencies:

Weekly Audits: 

1. Review accumulator and replenishment data for accuracy and completeness. 
2. Audit cash card claims to verify capture and proper attribution. 
3. Identify and track missing captures, incorrect accumulations, or potential diversion risks. 
4. Verify entity, prescriber, and patient eligibility documentation for compliance with HRSA definitions. 
5. Monitor claim data to confirm shared providers are accurately categorized within the 340B Program. 
6. Include telehealth claims in weekly reviews to ensure compliance with 340B policies and procedures. 
7. Maintain a weekly audit log of findings, resolutions, and corrective actions. 

Monthly Audits: 

1. Conduct monthly self-audits of 340B pharmacy operations and contract pharmacy data. 
2. Reconcile replenishment and invoice data between the TPA, Beacon, and McKesson. 
3. Perform true-up reviews to ensure manual adjustments, credits, and returns are properly reflected. 
4. Audit state Medicaid claims to prevent potential duplicate discount rebates. 
5. Evaluate patient eligibility in mixed-use and clinic settings by reviewing records, insurance coverage, and hospital status (if applicable). 
6. Filter out non-eligible transactions using Excel or similar data tools. 
7. Prepare monthly summary reports of audit findings, corrective actions, and trends for review by the 340B Coordinator. 

Quarterly Audits:

1. Perform comprehensive compliance audits of all covered entities to verify patient, prescriber, and location eligibility. 
2. Review samples of dispensed claims for proper documentation within EHR and TPA systems. 
3. Validate ship-to and bill-to replenishment accuracy and ensure alignment with HRSA guidance. 
4. Present quarterly audit results and compliance trends to the 340B Committee. 
5. Track and document corrective actions to ensure timely resolution. 
6. Conduct audits of all contract pharmacy relationships. 
7. Monitor all points of service where 340B participation occurs. 
8. Monitor utilization records and purchasing accounts. 
9. Identify compliance gaps and assist in implementing corrective measures. 
10. Coordinate external compliance assessments as needed. 
11. Maintain organized records of all self-audits and reports. 

External Audits:

1. Serve as the primary point of contact for internal and external 340B audits. 
2. Maintain continuous HRSA audit readiness. 
3. Coordinate data requests during HRSA or third-party audits. 
4. Oversee external compliance assessments. 
5. Maintain records of audit outcomes and resolutions. 

Collaboration, Reporting, and Operational Support:

1. Work collaboratively with Pharmacy, Finance, IT, Internal Audit, and Accounting. 
2. Provide compliance reports to internal departments. 
3. Develop tracking tools and reports. 
4. Participate in 340B Committee meetings. 
5. Support pharmacy operational activities related to the 340B Program, including retail pharmacy reporting, inventory management assistance, contract pharmacy coordination, and implementation support for new 340B partnerships or service line expansions. 

Professional Requirements:

1. Adheres to dress code; appearance is neat and professional.
2. Completes annual education requirements if applicable.
3. Maintains regulatory requirements.
4. Wears identification while on duty.
5. Attends annual evaluation and participates actively in this process.
6. Reports to work on time and as scheduled; completes work in designated time.
7. Attends all meetings as appropriate.
8. Exhibits the mission, ethics and goals of Mayers Memorial Hospital District in the performance of job duties.

WORKING CONDITIONS:

1. Willingness to work beyond normal working hours and in other positions temporarily when necessary.
2. Is involved with personnel, visitors and government agencies, etc., when necessary.
3. Must function independently, have personal integrity, have flexibility and the ability to work effectively with other personnel, clients and support agencies.

PHYSICAL REQUIREMENTS:

1. Sits, stands, bends, lifts, walks and moves intermittently during working hours.
2. Able to lift 40 lbs.

Salary : $24 - $30