Pharmacy Access Representative III - Home Infusion

Pharmacy Access Representative III

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

The Pharmacy Access Representative III (PAR) is responsible for the overall financial management and coordination for home infusion referrals including removal of barriers that prevent patients from receiving their medications. Duties will include insurance coverage determination, patient out of pocket determination, determination of prior authorization requirements. The PAR will communicate with the prescriber's office to acquire necessary information and assembly of documentation necessary to submit claims to the patient's insurance for approval including prior authorization and helping enroll patients in financial assistance programs. The PAR will link communication between the referral source, patient, pharmacy, insurance, and staff to ensure coordinated care. The PAR will be assigned to incoming referrals or a set of patients to manage along with a pharmacist. 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, medical/clinical staff, and central prior authorization 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.

Responsibilities:

• Coordinates medication and supplies coverage with referral sources and pharmacy staff to ensure timely financial approval. Coordinates and troubleshoots insurance issues with referral sources, pharmacists, physicians, and staff to prevent treatment interruptions.
• Acts as a liaison between home care coordinators, hospital discharge coordinators, home infusion staff and providers to obtain accurate information for home infusion billing.
• Coordinates medication financial approval, prior to ordering and dispensing with pharmacy for high cost medication.
• Makes scheduled calls to patient to convey out of pocket expense and determine insurance changes. Facilitates adherence to medications by ensuring that patients receive prescribed medications in a timely manner.
• Provides excellent customer service. Triages patient and referral calls to appropriate party. Answer incoming calls in a timely manner.
• Monitors and reconciles patient self pay accounts once a month. Contacts patients per determined procedure.

Financial Management:

• Maintains expertise on all insurance coverage related activities for medical benefit and pharmacy benefit plans.
• Retrieve and evaluate incoming home infusion referrals to verify insurance coverage and contract for infusion therapy including drug, supplies or per diem, and nursing when required. 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 home infusion therapy 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 such as Patient Assistance Programs, charity care, specific disease state grants, and social work funds.
• Confirm or create delivery tickets for provided services and work collaboratively with respective service lines that are needed to assemble information necessary for billing.
• Maintains expertise on all potential patient assistance programs (PAP), grants, foundations, and coupons relevant to the high-cost drugs prescribed in their assigned area(s).
• Analyzes patients that are receiving high-cost medications for potential participation in PAPs, 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 PAP options to the patient/family when there are multiple options.
• Enrolls patients in PAPs using the needed permission and information, followup to determine the status of the application, and ensure proper documentation of this process. Submits all required documentation to the PAP throughout the duration of treatment to verify payment for each prescription refill is still active. Understands and manages the payment process specific to each PAP, and assures that payments are properly accounted for the correct patient and correct patient encounter.
• Meets or discusses with the patient and/or family the status of PAP eligibility on an as-needed basis if coverage changes during treatment duration.
• Serves as a subject matter expert available to patients, providers and other staff about financial assistance resources, including PAPs, grants, foundations, manufacture coupons, and social work.
• 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 prescription 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 Management:

• Maintains expertise of the current policies of the most common payors for the relevant administered drugs 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.

Minimum Education & Experience:

• At least 18 years of age at the time of application required
• Associate's degrees in Medical, Secretarial, or related field or equivalent combination of education and experience required
• Minimum of four years of relevant experience or equivalent combination of education and experience required

Knowledge, Skills & Abilities:

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

Licenses and Certifications:

• Complete ASHP accredited training program or equivalent experience as a pharmacy technician, or Certification from a nationally accredited pharmacy technician certification program (Currently PTCB) and maintain ongoing education requirements preferred.