Intake/Utilization Mgmt Specialist Full time Days

Description The Intake Specialist, Home Infusion Pharmacy reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. This role serves as the point-of-entry for the Home Infusion Pharmacy department. Responsibilities Engages in front-end utilization management and per-protocol onboarding procedures to ensure a safe, efficient, and accurate intake process for the pharmacy. Actively and effectively serves as a remotely functioning liaison for the home infusion pharmacy to case managers, social workers, physicians, and other referring partners. Monitor and respond to requests for Home Infusion Pharmacy services in an efficient, accurate, and professional manner via several platforms such as email, phone, and Allscripts/Careport, to name a few. Exercise autonomy when scrutinizing prospective referrals for acceptance. Navigate and leverage tools to make informed decisions about referral acceptance and denial. Maintain and update reference tools, as appropriate. Conduct eligibility verification, benefits investigation, test claims (when applicable), and prior authorizations for all cases related to Home Infusion Pharmacy. Assist in the coordination of appeals for prior authorization denials, when indicated. Must have ability to navigate and execute functions within health insurance electronic portals and/or communicate with payor representatives via telephone. Actively communicate with members of the care management team, patient care team, and pharmacy to provide status updates on referrals. Communication mode (email, phone, progress note, warm hand-off, etc.) may vary depending on the audience and situation. Work with Pharmacy software (CPR+) to create patient profiles and document communication notes in order to keep the Pharmacy team abreast of new information. Provide accurate information and timely updates to patients and customers. Addresses questions and concerns promptly, or identifies appropriate person and resources to do so. Participates in efforts to reduce costs, streamline work processes, improve and grow services provided. Utilizes department and hospital policies and procedures to complete assigned tasks. Demonstrates knowledge and compliance with insurance, local, state and federal regulations related to physician and hospital billing. Has a firm understanding of those home infusion services covered by commercial and federal payers. Participate in team meetings, quality improvement initiatives, and other activities as requested. Assist with the onboarding and training of new members of the team. Other responsibilities as assigned and indicated Qualifications Required: High School Diploma Two (2) years progressive work experience in any one of the following: hospital/physician utilization management. Also acceptable: retail pharmacy/PBM/Home Infusion as a billing representative, UM professional, patient services representative, and/or pharmacy technician. Knowledge of EPIC systems, Microsoft applications, referral platforms such as Allscripts/Careport, and CPR+. If has not engaged in these applications, must have the ability to quickly learn. Ability to manage multiple priorities in a fast-paced environment. Exceptional organizational skills and detail orientation which includes ability to prioritize tasks and keep records so they remain readily retrievable. Excellent customer service and communication skills Experience that has contributed to the understanding of insurance rules and regulations, especially Medicare and Medicaid. Preferred: 2+ years college or college degree Five (5) years progressive work experience in any one of the following: hospital/physician utilization management. Also acceptable: retail pharmacy/PBM/Home Infusion as a billing representative, UM professional, patient services representative, and/or pharmacy technician. Call center, telephone work experience High-level problem solving, analytical, and investigational skills Equal Opportunity Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Background Check Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please refer to the Benefits Eligibility by Employment Classification to determine benefits eligibility for job postings. If sign-on bonus is included in a job posting eligibility is as followed: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign-on bonus. Exception: New graduate internal employees seeking their first licensed clinical position as a Registered Nurse at NM may be eligible. #J-18808-Ljbffr Northwestern Medicine