Pharmacy 340B Program Coordinator - Pharmacy- FT exempt
Description
Salary Range: $92,000 - $133,000.00
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
Job Description
Division: Pharmacy Department, Operations and Support Division
Job Title: Pharmacy 340B Program Coordinator
Position Summary
Job Code: 09C
Pharmacy 340B coordinator under the direction of the Director of
Pharmacy is responsible for managing the daily administration,
analysis and operation of the 340B Drug Program and all its
components including compliance and program regulations. Ensures
that the 340B program is continuously compliant with 340B federal
regulations.
Reports to: Director of Pharmacy
Statement of
Accountability
Required Qualifications
Qualifications
1.
California State Board of Pharmacy Technician Registration and
Pharmacy Technician National Certification, maintained in active
status and available for primary source verification.
Certification from Apexus 340B University course required within 3
months of hire; maintains current knowledge as Apexus and HRSA
guidance is updated.
• Education
• Licensure
2.
• Work Experience
• Skills/computer/ specific
technical
3.
4.
Two (2) year degree (or expected completion within one (1) year) or
better.
Completes hospital orientation, initial competency assessment, and
all required annual compliance education (including HIPAA,
workplace violence prevention, and safety) within required
timeframes.
• Other qualifications,
miscellaneous
Specify if qualifications are
required or preferred
Preferred Qualifications
1.
2.
3.
Bachelors’ degree in science or finance or MBA preferred
Apexus Certified Expert (ACE) 340B credential preferred.
Working knowledge of 340B Drug Program and contract pharmacy
operations preferred. Familiar with 340B split billing software and
configurations.
4.
5.
6.
7.
Two years of pharmacy purchasing and inventory management
experience or related experience preferred.
Ability to use Microsoft Office products including Excel, Word, and
Outlook.
Critical thinking skills are imperative for the analysis of 340B
program.
Ability to analyze, understand, and use statistical and financial report
data to identify issues, trends, or exceptions to drive improvement of
results and find solutions.
8.
9.
Leadership skills are required to effectively implement changes
throughout the organization to improve the 340B program.
Must have good organization skills, work independently and prioritize
multiple projects and objectives in a rapidly changing environment.
Working knowledge of duplicate discount prevention across Medicaid
fee-for-service and managed care, and of Medicare Part B and Part
D 340B billing and reporting requirements, preferred.
10.
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
11.
Familiarity with manufacturer contract pharmacy restriction policies,
manufacturer claims data submission platforms, and rebate model
designs preferred.
Essential Job Responsibilities
1.
Reviews policies and procedures to ensure effectiveness and
compliance with state and federal regulations related to 340B
program management and contract pharmacy operations as needed.
Serves as primary internal, external program coordinator and
institutional “compliance expert or authority” for all 340B-related
matter regarding program details, policies, and procedures of the
virtual inventory processes required for mixed-use areas.
Acts as the liaison with necessary affiliated departments to ensure
340B program integrity.
Achieving Results
Key Components: assess,
plan, evaluate,
2.
demonstrate initiative,
quality of work,
productivity
3.
4.
Provides oversight and leadership from the department of pharmacy
for the 340B program. Will co-chair the organization’s 340B oversight
team, which will include representation from pharmacy, legal,
compliance, finance, and senior administration.
5.
6.
Provides expertise and education to the 340B program with staff and
participants regarding ongoing compliance.
Develops and maintains internal relationships (accounting, legal,
national) and external relationships (wholesalers, manufacturers,
contract pharmacies, split-billing software vendors, employee benefit
pharmacy benefits managers (PBMs), and third-party administrator
(TPA) vendors) as needed.
7.
8.
Acts as a liaison to the department of pharmacy and regional
facilities as well as with the organization’s purchasing office.
Actively engages with senior leadership and participates in decision-
making processes related to the implementation of new 340B
processes.
1.
Takes a lead role in the development, planning and integration efforts
related to the 340B program. Ensures that policies and procedures
are developed and implemented according to organizational,
regional, national, state, and federal requirements and guidelines are
approved by appropriate committees and legal department.
Completes and ensures regular compliance to the audit program and
recommendations from 340B consultants.
Demonstrates Skill
Key Components:
competency, job
knowledge,
organizational skills,
analytical skill,
management of
information, employee &
patient safety
2.
3.
4.
Contributes processes and materials to promote programs or support
the goals of the department and institution.
Establishes consistent policies and procedures for 340B that ensure
productivity and efficiency so that long-term management of the
program does not hamper operations or create unnecessary costs.
Develops and modifies 340B policies in accordance with state,
federal, and system program requirements as needed.
5.
6.
7.
Responds to all requests regarding 340B activities.
Collaborates with 340B contract pharmacy vendors and pharmacy
wholesalers to support the contract pharmacy network as needed to
maximize operational efficiency.
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
8.
9.
Provides problem resolution and appropriate follow-up with the
vendor and wholesalers when necessary.
Maintains a collaborative relationship with contract pharmacies and
provides timely resolution and/or communication of any issues, when
these relationships are established.
10.
Serves as the primary link between wholesale distributors, contract
pharmacies, manufacturers, legal counsel, prime vendor program,
supply chain, 340B Health, split-billing software vendor, HRSA/OPA,
pharmacy leadership and others as it relates to the operation and
management of contract and 340B program business to ensure
compliance.
11.
12.
Coordinates 340B needs with the buyer and Pharmacy IT.
Reviews and provides recommendations to pharmacy leadership on
pharmacy contracting and other 340B opportunities and strategies
while assessing the impact from a financial, clinical and operational
perspective.
13.
14.
Maintains the mapping of the split-billing software, works to ensure
340B drug purchases maximize pharmaceutical cost savings and
works in conjunction with Revenue Integrity to investigate, correct,
and modify any billing NDC discrepancies and pricing issues.
Assists Pharmacy Buyer and Pharmacist, as needed, for
GPO/WAC/340B purchase determination and preparing invoices and
purchasing/financial reports. Manages and tracks 340B drug
inventory, proper replenishment, exclusions, shortages and
establishes appropriate alternative products.
15.
16.
Designs an efficient process to reconcile any issues with drug
ordering, delivery and payment.
Remains informed of changes in policies or procedures, 340B
related legislation, articles, white papers, and document briefs that
could affect the program structure.
17.
18.
Assures appropriate safeguards and 340B integrity.
Develops and monitors standard operating procedures for the 340B
program in its entirety and contract pharmacies as needed.
Works with contract pharmacies to develop standard operating
procedures for 340B multiple contract pharmacy processes as
needed.
Provides periodic reports to the Director of Compliance regarding
adherence to 340B, audit results (internal and external),
effectiveness and regulatory updates.
19.
20.
21.
22.
Tracks, trends, and reports 340B pharmaceutical sales and
purchases data to ensure provider/physician and patient eligibility.
Maintains the accuracy and completeness of the hospital’s records in
the 340B Office of Pharmacy Affairs Information System (OPAIS),
including covered entity, child site, and contract pharmacy
registrations; completes annual recertification within the HRSA-
designated period and submits registrations and change requests
within the applicable registration windows.
23.
Administers duplicate discount prevention for Medicaid, including
carve-in/carve-out decisions, Medicaid Exclusion File entries and
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
billing identifiers, Medicaid managed care arrangements, and state-
specific billing and modifier requirements, including Medi-Cal.
Coordinates nonduplication between 340B and the Medicare Drug
Price Negotiation Program, verifying that selected drugs are acquired
at the lower of the 340B ceiling price or the maximum fair price
(MFP) and that no unit receives both discounts; supports enrollment
of dispensing pharmacies with the Medicare Transaction Facilitator
(MTF) and reconciliation of retrospective MFP refunds.
Evaluates and, where the hospital elects to participate, coordinates
submission of Part D 340B claims data to the CMS Medicare Part D
Claims Data 340B Repository, and maintains readiness for expanded
or mandatory 340B claims data reporting.
Monitors the status of manufacturer rebate models and any HRSA
rebate model pilot, maintaining operational and financial readiness to
submit claim-level data, model cash flow impact, and reconcile
rebates should such models take effect.
Tracks manufacturer contract pharmacy restriction policies and
associated data submission requirements; maintains required
pharmacy designations, evaluates the financial impact of each policy,
and escalates access issues to pharmacy, finance, and legal
leadership.
24.
25.
26.
27.
28.
29.
Verifies 340B ceiling prices against HRSA-published pricing,
identifies suspected overcharges, and pursues credits or refunds
from manufacturers and wholesalers, escalating unresolved matters
for consideration under HRSA’s administrative dispute resolution
(ADR) process.
Monitors federal and California legislative, regulatory, and litigation
developments affecting 340B eligibility, contract pharmacy access,
PBM reimbursement practices, and provider reporting obligations,
and advises leadership on operational and financial impact.
1. Ability to communicate effectively verbally and in writing, good
presentation skills, team building and educational teaching skills to
provide ongoing training for the 340B program.
2. Ability to work effectively with a variety of personnel with backgrounds
varied in education and skill sets.
Planning & Coordinating
Key Components:
delegates, decision
making, problem solving,
management of
3. Must be able to function as a team leader.
resources
4. Must have good negotiation skills and be able to interact with internal
staff, system vendors and outside consultants in a professional,
effective method.
5. Reports savings of the program [monthly, quarterly, etc.].
6. Assesses opportunities for cost savings and business improvement in
340B contract pharmacy utilization and prepares statements for this
purpose as needed.
7. Collaborates with departments, sites and staff representatives to
communicate improvements and promote broad participation in 340B
activities across the organization.
8. Leads and facilitates priority 340B projects to the final outcome.
9. Assists Pharmacy Director and CFO with HRSA and manufacturer
audits.
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
10. Performs quality assurance audits on all aspects of the organization’s
340B program on a continuous basis including contract pharmacy
operations, financial transactions, and patient and provider
qualifications.
11. Evaluates OPA database accuracy for eligible sites and compliance.
12. Reviews 340B purchase history to ensure that drugs being purchased
on 340B accounts are drugs being utilized accurately for outpatient
use.
13. Evaluates 340B inventory replenishment to confirm that accumulation,
reduction and reconciliation are occurring as expected as needed.
14. Prepares audit findings, reports, graphs, and charts of data analysis
and delivers presentations to work group committee on a regular
basis.
15. Prepares conclusions, predictions, and develops recommendations
based on research to track and manage essential aspects of the
program and make improvements and/or ensure compliance.
16. Monitors changes that have been made per recommendations to
evaluate success and suggests further improvements based on
results.
17. Serves as the hospital’s primary contact for HRSA and manufacturer
audits, coordinating document production, sampling responses,
corrective action plans, and any required self-disclosure and
repayment to affected manufacturers.
18. Conducts and documents self-audits at a frequency and scope
sufficient to demonstrate program integrity, covering patient and
provider eligibility, child site and contract pharmacy compliance, the
GPO prohibition and orphan drug exclusion as applicable to the
hospital’s covered entity type, and duplicate discount prevention.
1.
The Pharmacy 340B Coordinator frequently performs duties
following a pre-determined work routine, constantly organizing
his/her work within a frequently crowded, hectic, and noisy
environment.
The ability to constantly follow direction with high attention to detail is
critical and essential to patient safety.
The ability to exercise independent judgment and discretion to
choose optimal solutions and prioritize his/her work.
Must display appropriate interpersonal skills while working
productively and efficiently in a team atmosphere.
Patient confidentiality must be continuously observed.
Attention to detail and neatness is required continuously during the
everyday activities in which the Pharmacy 340B Coordinator involves
his/her workday (evidenced by preciseness in task performance and
orderliness of the work area).
Professionalism
Key Components:
dependability,
interpersonal skills,
teamwork, patient first
ethic, customer service,
communication skills,
punctuality/attendance,
receptiveness to
2.
3.
4.
criticism, judgment,
confidentiality
5.
6.
7.
8.
This position must allow for critical or emergent situations and
complete assigned routine work tasks.
The Pharmacy 340B Coordinator must be capable of applying new
information immediately and consistently.
9.
Be collaborative at all times.
10.
Respect privacy and confidentiality at all times.
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
11.
Demonstrates the values and behaviors of the organization.
1. Assesses opportunities for cost savings and system improvements to
Improving the
Organization
Key Components:
performance
yield higher compliance.
2. Analyzes utilization of the program and existing software to identify
ways to compliantly use the 340B program to its fullest extent to meet
the needs of underserved patients.
3. Works directly with the manufacturers as well as the wholesalers to
develop strategies for appropriate use of the program.
4. Participates in projects, councils, and special initiatives related to
340B, compliance, auditing functions, vendor selection, and
medication management.
improvement, quality
initiatives
5. Develops business plans to prioritize and implement programs related
to program services and contract pharmacy agreements.
6. Develops action plans to close identified gaps in collaboration with
organizational leadership.
7. Participates in projects, councils, and special initiatives related to
340B.
8. Implements business plans in coordination with pharmacy leadership
to help use 340B savings to expand and improve care provided to
underserved and vulnerable populations.
9. Monitors all outpatient points of service to continually check for new
areas that may qualify for the 340B program.
10. Provides oversight for the implementation of process improvement
initiatives and creates an environment that places an emphasis on
continuous monitoring and improvement.
11. Participates in departmental performance improvement activities.
Prepares and analyzes data.
12. Integrates information from the pharmacy charge master system into
the 340B split-billing systems and incorporates that information into
auditable and compliant processes.
13. Contributes 340B program data, audit results, and corrective action
outcomes to the hospital’s performance improvement program (LD
12.01.01) and supports continuous survey readiness between survey
cycles.
1. Maintains knowledge of the policy and standards changes that affect
the 340B program, including, but not limited to, HRSA/OPA rules,
Medicaid changes, and Joint Commission Accreditation 360 standards
and National Performance Goals.
2. Provides expertise on all 340B program legislation and policy changes
from HRSA and OPA, informing and collaborating with legal and
compliance teams.
Self-Development
Key Components: maintain
license/certification,
education and training
3. Maintains licensure/certification in active status and supplies
documentation required for primary source verification of credentials
(HR 11.01.03).
4. Completes competency assessment at orientation and at least once
every three years, or more frequently as determined by the
organization (HR 11.04.01, EP 1).
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
5. Participates in ongoing education and training necessary to maintain
or increase competence, including 340B-specific training (HR
11.03.01).
6. Attends and completes all required health and safety classes,
updates, and health screenings/testing (NPG Goal 12).
7. Seeks out opportunities to learn and apply best practices.
8. Must be able to demonstrate the knowledge and skills necessary to
provide care and/or service based on the physical, psycho/social,
educational, safety, and related criteria appropriate to the age of the
patients served in his/her assigned service area.
9. Maintains current knowledge of HRSA/OPA guidance, Apexus
resources, CMS rulemaking affecting 340B, and state legislative
developments, and briefs pharmacy leadership on changes affecting
the program.
1. Demonstrates awareness of and compliance with regulatory standards;
i.e., 340B federal requirements (HRSA Office of Pharmacy Affairs),
CMS Conditions of Participation — including Pharmaceutical Services
(42 CFR §482.25), Joint Commission Accreditation 360 standards and
National Performance Goals (NPGs), Title 22, HIPAA, and other
service specific regulations.
2. Supports compliance with Joint Commission Medication Management
(MM) requirements as they apply to 340B purchasing, storage, and
inventory, including management of drugs and biologicals in
accordance with federal and state law (MM 11.01.01), the medication
formulary (MM 12.01.01), and medication storage, records and
disposition, and removal of expired or otherwise unusable medications
from patient use (MM 13.01.01).
Regulatory Compliance
Key Components: Joint
Commission
Accreditation 360
standards and National
Performance Goals
(NPGs), CMS Conditions
of Participation, Title 22,
OIG, HIPAA,
State/Federal laws,
hospital policies
3. Ensures 340B accumulation, replenishment, and split-billing practices
do not compromise medication safety expectations under National
Performance Goal 14 (medication management program focused on
safety), including standardized drug concentrations and management
of medication shortages (NPG 14.02.01).
4. Maintains 340B records, reports, and split-billing data consistent with
Information Management requirements for privacy, confidentiality,
security, and integrity of health information (IM 12.01.01 and IM
12.01.03), and uses only approved standardized terminology,
abbreviations, acronyms, symbols, and dose designations (IM
13.01.01).
5. Employees in this position have access to protected health information
(includes demographics, date of service, insurance/billing, medical
record summary information, and all other information that may be
contained in patient records).
6. Maintains 340B policies and procedures within the hospital’s policy
framework (LD 13.01.09), supports leadership in demonstrating
compliance with law and regulation (LD 13.01.01), and supports
oversight of contracted services, including contract pharmacies, split-
billing vendors, and third-party administrators (LD 13.03.03).
7. Maintains continuous survey readiness for all 340B-related
documentation and participates in tracer activity, medication
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
Docusign Envelope ID: 7A5B3479-9D4C-88D2-83E5-044BBCB62EF5
management and pharmacy review sessions, and document review
during Joint Commission and CMS surveys, using the Survey Process
Guide as the reference for survey expectations.
8. Demonstrates awareness of legal issues in all aspects of patient care,
promoting safe practice in order to reduce risk.
9. Knows and complies with all Hospital safety policies and procedures
as identified in the Hospital Safety Manual, Disaster Preparedness
Manual and the Employee Safety Handbook, including Physical
Environment (PE) requirements.
10. Completes workplace violence prevention training and reports
workplace violence events in accordance with hospital policy (NPG
02.04.01, EP 2), supporting the organization’s workplace and patient
safety goal (NPG Goal 11).
11. Knows and uses the right safety practices and equipment or materials.
12. Takes immediate action and/or reports to supervisor or other
appropriate personnel any potential unsafe condition, practice or
hazard.
13. Immediately reports every work related injury.
14. Maintains compliance with 340B program integrity requirements under
section 340B of the Public Health Service Act (42 U.S.C. §256b),
including the prohibitions on diversion to ineligible individuals and on
duplicate discounts, the group purchasing organization (GPO)
prohibition and orphan drug exclusion as applicable to the hospital’s
covered entity type, and adherence to the hospital’s definition of an
eligible patient and eligible prescribing/service locations.
15. Maintains auditable 340B records sufficient to demonstrate compliance
to HRSA, manufacturers, and the hospital’s compliance function
throughout the applicable audit look-back period and at annual
recertification.
Prepared by:
Approved by:
Minh-Thu Dennen
Title: Director of Pharmacy
Date: 07/2026
Date:
Title: Sr VP & Chief of
Operations
7/28/2026
Date:
7/29/2026
Personnel Office Review: __________________________
Revised Date:
2000 Mowry Avenue
Fremont, CA 94538
510.797.1111
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