Pharmacy Access Representative III - Home Infusion

University of Rochester•Rochester, NY

2d•$22 - $29•Onsite

About The Position

The Pharmacy Access Representative III (PAR) is responsible for the overall financial management and coordination for home infusion referrals, including the removal of barriers that prevent patients from receiving their medications. Duties will include insurance coverage determination, patient out-of-pocket determination, and determination of prior authorization requirements. The PAR will communicate with the prescriber’s office to acquire necessary information and assemble documentation necessary to submit claims to the patient’s insurance for approval, including prior authorization, and help 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 judgment, 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, such as 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.

Requirements

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
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

Nice To Haves

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.

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 patients 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 the appropriate party.
Answers incoming calls in a timely manner.
Monitors and reconciles patient self-pay accounts once a month.
Contacts patients per determined procedure.
Maintains expertise on all insurance coverage related activities for medical benefit and pharmacy benefit plans.
Retrieves and evaluates incoming home infusion referrals to verify insurance coverage and contract for infusion therapy, including drug, supplies, or per diem, and nursing when required.
Obtains 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.
Determines if home infusion therapy being ordered meets payer requirements for coverage.
Retrieves and assembles necessary information for insurance coverage qualifications as needed.
Communicates out-of-pocket costs to patients, caregivers, or coordinators.
Identifies coverage gaps and utilizes resources such as Patient Assistance Programs, charity care, specific disease state grants, and social work funds.
Confirms or creates delivery tickets for provided services and works 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 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, follows up to determine the status of the application, and ensures 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, manufacturer coupons, and social work.
Collaborates with social services and case management on patient assistance.
Remains professional, courteous, and diligent in all interactions with staff and patients/families.
Obtains high patient and provider satisfaction results.
Reports errors through the hospital error reporting system (RL solutions) and contributes to quality improvement initiatives.
Assists with prescription audits and ensures timely completion of required patient documentation.
Coordinates required information for denied claims.
Participates in payer audits and collects, summarizes, and sends requested information.
Assists with training of new team members in the designated clinical area.
Performs other related duties as required, including work relating to the Intake Pharmacy Access Representative.
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.
Submits and monitors prior authorization requests timely.
Initiates, documents, and tracks all prior authorizations on behalf of the areas to improve patient experience, ensure compliance, and prevent interruptions or delays in treatment.