Pharmacy Access Rep III - DME

Responsibilities: The Pharmacy Access Representative III (PAR) is responsible for the overall management of medical equipment and supplies, coverage determination, and removal of barriers that prevent patients from receiving their equipment. Duties will include insurance coverage verification and determination, patient cost estimation, assembly of documentation necessary to ensure payment for equipment in compliance with payer standards. The PAR will communicate with the prescriber's office to acquire necessary information to submit claims to the patient's insurance for approval including prior authorization and helping educate patients with financial need and arrange timely delivery of the equipment. The PAR will link communication between the patient, referral source, insurance, and staff to ensure coordinated care. The PAR will be assigned to a general service area such as hospital discharges and respiratory care Daily tasks are completed independently and prioritized based on the patient and pharmacist needs. Duties of this position require proper judgement, sensitivity, and strict adherence to Strong Memorial Hospital policy on confidentiality and the protection of Private Health Information. The PAR interacts with multiple individuals within the institution including, but not limited to, hospital and clinical employees at various levels including pharmacists, pharmacy technicians, and medical/clinical staff. External interactions include third party payors, governmental peer review organizations, and referring physicians. To be successful, this individual must have excellent phone etiquette and be open to feedback to create strong collaborative work relationships.

Essential Functions: Coordinates Home Medical Equipment (HME) and supplies referrals and delivery coordination with home medical equipment staff to ensure timely delivery. Troubleshoots insurance issues with referral sources,, physicians and other clinical and internal staff to prevent interruptions in receiving equipment or therapy. Acts as liaison between home care coordinators, discharge coordinators DME staff and providers to obtain accurate information related to coverage requirements for medical equipment. Coordinate delivery utilizing various options such as UR DME technicians, UR Couriers and other commercial services. Coordinate resupply for consumable items such as CPAP/BIPAPStaff HME storefront locations; assist patients with selection and purchase of equipment, as well as educates them on the different options that are covered with their insurance. If insurance does not cover the equipment needed, they support the patient in finding alternative programs to cover the cost of the equipment. Follow-up with patients to ensure safe and effective equipment use. Documents problems with the equipment (i.e. delivery issues, broken equipment, monitors CPAP and other respiratory equipment use and adherence, difficulty with use, etc.) and triages issues to management and clinical staff as appropriate. Coordinates medical equipment ordering with inventory manager. Tracks changes in ordering trends and coordinate with inventory manager if changes in stock on hand is needed. Makes scheduled calls to patient to determine resupply needs and set up deliveries. Facilitates adherence to treatment by monitoring compliance and communicating with patients and clinical staff. Provides excellent customer service. by Triaging patient calls to appropriate party. Answer incoming calls in a timely manner. Monitors and reconciles patient self-pay accounts once a month. Financial ManagementMaintains expertise on all insurance coverage and requirements for home medical equipment. Retrieve and evaluate home medical equipment referrals to verify insurance coverage and contract for equipment. Obtain benefit information from third party payers to advise patients on their expected out of pocket costs taking into account deductibles, coinsurance, copayments or total charges if services are not covered. Determine if equipment being ordered meets payer requirements for coverage. Retrieve and assemble necessary information for insurance coverage qualifications as needed. Communicates out of pocket costs to patients, care givers or coordinators. Identifies coverage gaps and utilizes resources through social workers, charity care or other assistance programs. Serves as a subject matter expert available to patients, providers, social work, and others regarding alternative payment methods such as Chairty care. Creates and confirms sales orders for equipment provided and work collaboratively with respective service lines that are needed to assemble information necessary for billing. Analyzes patients that are high-cost equipment for potential options and identifies the best option(s) for the patient given their overall circumstances (insurance, disease state, income, etc.). Coordinates with the patient and/or family to obtain necessary information including income information and other personal details, as well as to present options to the patient/family when there are multiple options. Collaborates with social services and case management on patient assistance.

Compliance and Quality: Remains professional, courteous and diligent in all interactions with staff and patients/families. Obtains high patient and provider satisfaction results. Reports errors through hospital error reporting system (RL solutions) and contribute to quality improvement initiatives. Assists with payer audits and ensure timely completion of required patient documentation. Coordinate required information for denied claims. Participate in payer audits and collect, summarize and send requested information. Assists with training of new team members in designated clinical area. Performs other related duties as required, including work relating to the Intake Pharmacy Access Representative Prior Authorization ManagementMaintains expertise of the current policies of the most common payors for the relevant equipment that require prior authorization (PA), and will be responsible for working with the prior authorization coordinators, office staff nurses and other patient care staff to assure that all required elements of the policy are applicable in advance of requesting PA. Submit and monitor prior authorization requests timely. Initiates, documents, and tracks all prior authorization on behalf of the areas to improve patient experience, ensure compliance, and prevent interruptions or delays in treatment.

Knowledge, Skills & Abilities: Capable of working independently with minimum supervision required. Exhibit strong communication skills, problem-solving abilities, andprofessional presentation required. Demonstrate customer relations skills required. Individual must be able to multi-task, manage many details with accuracy, work under pressure, and maintain a professional attitude required.

Licenses and Certifications: Completed ASHP-accredited training program or equivalent experience as a pharmacy technician preferred. Certification from a nationally accredited pharmacy technician certification program (Currently PTCB) and maintain ongoing education requirements preferred. The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University's Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.