Full Time 40 hours Grade 008 Pharmacy SMH
8 AM-4:30 PM
This individual is responsible for the overall management of drug access for high-cost specialty and restricted access drugs in assigned clinics. Duties will include collaboration with clinical staff to acquire prior authorization for relevant providers, benefit investigation, enrollment of patients in appropriate patient assistance programs, managing the vendor payment process for the assistance programs, and collaboration with patient financial services to assure accurate billing for the patient self-pay obligation. This overall program is intended to facilitate access to clinic-administered drugs while also maximizing the revenue and margin associated with the provision of these high cost drugs through retention of supply chain management within Strong Memorial Hospital.
This position has independent responsibility for organizing and planning work in order to accomplish daily work requirements. A substantial portion of the normal duties of the incumbent requires proper judgement, sensitivity, and strict adherence to Strong Memorial Hospital policy on confidentiality and the protection of Private Health Information. The incumbent interacts with multiple individuals internal and external to the institution including hospital and clinical employees at multiple levels including pharmacists, medical/clinical staff, fiscal personnel, department managers, access services staff, coding staff and billing assistants. External contacts include third party payers, governmental peer review organizations, and referring physicians. To be effective this individual must be able to establish strong collaborative working relationships.
Prior Authorization Management
Highly knowledgeable of the current policies of the major payers for the relevant clinic-administered drugs that require prior authorization (PA), and will be responsible for working with the clinic providers, nurses and other patient care staff to assure that all required elements of the policy are applicable in advance of requesting PA.
Take primary responsibility for submitting PA requests to the payers for clinic-administered drugs, and managing the submission of any supplemental information that is requested.
Review all denials for PA to determine the reason the request was denied and preparing a response to the payer with necessary additional information. If the denial management will need to involve other clinic staff or providers, the required individuals will be engaged and a summary of all actions taken to date along with supporting documentation will be provided.
Notify the relevant provider and provide the physician with needed documentation and summary of actions taken to date, if a letter of medical necessity is needed or if physician-to-medical director conversation is needed for approval outside of the payer policy.
Document all PAs in the appropriate location within the electronic medical record include the PA number and dates of approval.
Track all PAs to assure that they are renewed on a timely basis to prevent interruptions or delays in treatment.
Patient Assistance Program Management
Highly knowledgeable and will remain up-to-date on all potential patient assistance programs (PAP) relevant to the high-cost, clinic-administered drugs used in the assigned clinic(s).
Prospectively evaluate every patient receiving high-cost, clinic-administered drug therapy for potential participation in PAPs, and identify the best option(s) for the patient given their overall circumstances (insurance, disease state, income, etc). This will often involve meeting with and interviewing the patient and/or family to obtain necessary information which may include income information and other personal details, as well as to present PAP options to the patient/family when there are multiple options.
Enroll patients in PAPs using the mechanisms that are required for each program, and will follow-through to assure the PAP is approved and properly documented in the electronic medical record.
Submit all required documentation to the PAP throughout the duration of treatment to assure payment for each dose administered, as well as assure continued coverage for the maximum amount of assistance available.
For governmental payers where PAPs may represent no-cost drug that is provided from an outside pharmacy/distributor, responsible for managing the patient specific inventory so that it is available for administration on treatment days, and will also make sure documentation is appropriate to suppress any patient charge for the medication itself.
As needed, meet or discuss with the patient and/or family the status of PAP eligibility if things change during care.
Serve as a general resource available to patients, providers and other clinic staff about PAPs.
As part of the patient intake process, conduct a benefits investigation for high-cost, clinic administered drugs and will be able to discuss the patient obligation for treatment with the patient and/or family.
Responsible for understanding and managing the payment process specific to each PAP, and assures that payments are properly applied to the correct patient and correct patient encounter.
If needed, assure that the PAP is set-up within the electronic medical record revenue application as a secondary or tertiary payer.
Must work collaboratively with Patient Financial Services to assure that patient bills are held pending payment from the PAP, and that the final bill sent to the patient accurately reflects the patient's obligation after payment is received from the PAP.
Track all payments received from PAPs, and will provide monthly, quarterly and annual reports summarizing the patient out-of-pocket savings attributed to PAP payments received.
Track all no-cost drug received for patients with governmental payers, and quantify the savings realized by the patient or institution on a monthly, quarterly and annual basis.
Patient and Provider/Clinic Satisfaction
Professional, courteous and diligent in all interactions with staff and patients/families.
Collect patient satisfaction survey data on a regular basis to assess the level of patient satisfaction with the work of the medication access specialist, patient assistance program, and the overall drug management process.
Performs other related duties as required.
Associate's degree in Medical, Secretarial or related field or certified pharmacy technician (CPhT) and a minimum of three years of relevant experience required; or an equivalent combination of education and experience. Must be capable of working independently with minimum supervision. Strong communication skills, problem-solving abilities, and a professional presentation are essential and required. Medical terminology, experiences with medical/surgical scheduling software, and electronic medical records preferred. Demonstrated customer relations skills.
How To Apply
All applicants must apply online.
EOE Minorities/Females/Protected Veterans/Disabled
University Of Rochester