Pharmacy Reimbursement Specialist - Pediatric Outpatient

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 Rotate between day‑to‑day operations in the pharmacy and a decentralized location to deliver prescriptions to the appropriate floors/patients as needed. Utilize knowledge of the bed board, mobile heartbeat and prescription filling process to decentralized operations. Communicate with patients and families about their prescriptions and coordinate delivery of their prescription if desired. Communicate with nurses, residents, and physicians about medications for the patient, discharge time/date, and any challenges that may arise. Hours / Location Monday through Friday, 8‑hour daytime shifts. Located onsite at Monroe Carell Jr. Outpatient Hospital. Required Qualifications 2 years relevant work experience. Effective communication, strong organization skills, and self‑motivation is a must. PTCB/NHA National Pharmacy Technician Certification required. Tennessee Board of Pharmacy Technician Registration must be obtained within 90 days of employment. 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. Benefits 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. Equal Opportunity Statement 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