Pharmacy Reimbursement Specialist

Position Highlights: Hours are Monday - Friday 8:00am - 4:30pm. No weekends and no holidays. Responsibilities include obtaining prior authorizations for high-cost medications, calling and following up with insurance, verifying benefits, communicating with providers, nurses and clinics, eligibility for benefits, entering approvals from insurance appropriately, all in a fast-paced and high-volume environment. Prior authorization experience with high-cost medications is preferred.1 year of relevant pharmacy experience is required. This position has the potential to work remotely after the initial training and onboarding have been successfully completed with the exception of any in office training, etc.

Key Responsibilities: Clarify and trend pharmaceutical denials and underpayments of the highest cost drugs and other drugs. Utilizes data from finance and pharmacy systems to determine reimbursement rates for pharmaceuticals for various patient care settings. Evaluates actual reimbursement compared to defined contractual reimbursement rates for specific drugs/procedures. Provides trending on reimbursement and information on areas for focus to maximize reimbursement. Maintains data in appropriate database to facilitate evaluation and presentation of data. Evaluates data enabling the identification of trends by multiple variables. Work with patient accounting, finance, contracts and pharmacy to develop strategy for improved reimbursement. Utilizing data collected, defines areas for focus to maximize reimbursement and presents plan to above departments. Maintains list of potential opportunities for reimbursement and contracting based on proactive review of data. Works collaboratively to develop programs and procedures to maximize reimbursement of pharmaceuticals. Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals. Works with pharmacy staff and finance to evaluate reimbursement of new drugs and proposes necessary procedures to maximize reimbursement. Document enhanced reimbursement from developed programs and trend success of programs. Utilizing databases maintained to provide documentation to support the effectiveness of the reimbursement program. Assists with regulatory compliance related to safe medication use with program, operational, regulatory bodies (JCAHO, ASHP, state and federal regulations, Leapfrog, etc.), and institutional policies and procedures. Provides written monthly update on activities and financial impact of program to enhance reimbursement. Assists billing manager and documents regulatory compliance related to billing of pharmaceuticals and works to correct any variances. Work with Patient Assistance Programs (PAP) to include identifying new opportunities, document receipt of funds and provide proper adjustment of patient accounting accounts. Collaborates with pharmacy, finance, contracts and patient accounting to identify ongoing opportunities to expand the PAP to reduce drug cost. Documents savings from the PAP and provides a monthly report trending the savings from the program. Provide recommendations to pharmacy administration for input into hospital contracting for enhanced reimbursement. Maintains proper resources and contacts to understand the contractual reimbursement of pharmaceuticals. Maintains documentation on any issues with contractual reimbursement including the financial impact for review by pharmacy, finance and contracting. Contributes to the continuing education of pharmacy on the reimbursement of pharmaceuticals and the contractual trends for reimbursement.