Pharmacy Reimbursement Specialist 2 - Population Health

Discover Vanderbilt University Medical Center : Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health is committed to an environment where everyone has the chance to thrive and where your uniqueness is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research. Organization: Pop Health Rx Support Team Job Summary Evaluates reimbursement of medications provided to inpatients, clinic patients and patients receiving prescriptions through the outpatient pharmacy network. Works with multidisciplinary groups to develop proper procedures and programs to maximize reimbursement. Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals. Assists with maintaining drug and payer data files in the dispensing system. Works with dispensing staff and/or payor help desk staff to troubleshoot issues with medication claims, and when needed, editing / resubmitting claims in the OP dispensing system. Position Highlights Position includes working with Medicare Advantage Plans and patient adherence. Position will be located onsite for initial training and onboarding. Hybrid schedule available after training and onboarding have been successfully completed. Monday - Friday. No weekends. No holidays. Options for (4) 10-hour shifts or (5) 8-hour shifts. Must have 2 years of relevant experience. Must have a TN Pharmacy Technician license. Must be a Certified Pharmacy Technician through either PTCB or NHA in order to be considered. Retail/outpatient pharmacy experience and customer service experience are preferred. 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. As permitted by law, may receive or transfer oral prescriptions for dispensed medications under the supervision of a pharmacist. Core Accountabilities Organizational Impact: Performs tasks that are typically routine that may impact team's performance with occasional guidance. Problem Solving/ Complexity of work: Utilizes some discretion and research to solve routine problems. Breadth of Knowledge: Applies knowledge of standards, established processes and procedure that apply to your own job. Team Interaction: Provides guidance to entry level co-workers. Core Capabilities Supporting Colleagues: Develops Self and Others: Continuously improves own skills by identifying development opportunities. Builds and Maintains Relationships: Seeks to understand colleagues' priorities, working styles and develops relationships across areas. Communicates Effectively: Openly shares information with others and communicates in a clear and courteous manner. Delivering Excellent Services: Serves Others with Compassion: Invests time to understand the problems, needs of others and how to provide excellent service. Solves Complex Problems: Seeks to understand issues, solves routine problems, and raises proper concerns in a timely manner. Offers Meaningful Advice and Support: Listens carefully to understand the issues and provides accurate information and support. Ensuring High Quality: Performs Excellent Work: Checks work quality before delivery and asks relevant questions to meet quality standards. Fulfills Safety and Regulatory Requirements: Demonstrates basic knowledge of conditions that affect safety and reports unsafe conditions to the appropriate person or department. Managing Resources Effectively: Demonstrates Accountability: Takes responsibility for completing assigned activities and thinks beyond standard approaches to provide high‑quality work/service. Stewards Organizational Resources: Displays understanding of how personal actions will impact departmental resources. Makes Data Driven Decisions: Uses accurate information and good decision making to consistently achieve results on time and without error. Fostering Innovation: Generates New Ideas: Willingly proposes/accepts ideas or initiatives that will impact day‑to‑day operations by offering suggestions to enhance them. Applies Technology: Absorbs new technology quickly; understands when to utilize the appropriate tools and procedures to ensure proper course of action. Adapts to Change: Embraces changes by keeping an open mind to changing plans and incorporates change instructions into own area of work. Position Qualifications Certifications Certified Pharmacy Technician - National Healthcareer Association Certified Pharmacy Technician - Pharmacy Technician Certification Board Licensed Pharmacy Technician - Tennessee Work Experience Relevant Work Experience Experience Level 2 years Education Graduate of an approved discipline specific program This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth. Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity. EOE/Vets/Disabled. #J-18808-Ljbffr Direct Jobs