Pharmacy Operations - Access Specialist

Fairview Health Services•Minneapolis, MN

About The Position

The Pharmacy Operations - Access Specialist applies knowledge of insurance, revenue cycle, pharmacy services, and health system operations to coordinate patient care across acute care, ambulatory sites, Fairview Home Infusion, and Fairview Specialty Pharmacy. The role works with an interdisciplinary team that includes revenue cycle, service line, clinical, physician, and other health care staff in an academic/clinic environment. It offers experienced pharmacy professionals an opportunity to expand their knowledge base. The specialist identifies and resolves barriers to access for pharmacy services, including high-cost medications. The role assesses insurance benefits and patient information, coordinates appropriate sites of care, supports prior authorizations and appeals, helps patients understand financial responsibilities and assistance options, and communicates with patients, caregivers, clinics, pharmacy teams, payers, and outside facilities. The specialist also supports process improvements, staff education, and implementation of access for new drug therapies.

Requirements

Bachelor of Science or Bachelor of Arts degree in business or a healthcare-related field.
Five years of revenue cycle, financial counseling, pharmacy access services, or contracting experience in a healthcare or insurance organization.
Communication, interpersonal, and adaptability skills.
Willingness to work in a fast-paced environment, work independently, grow and develop, and contribute as an integral part of the team.

Nice To Haves

Experience in pharmacy, specialty infusion, home infusion, pharmacy medications, prior authorizations, and/or coordinating work with multiple stakeholders.
Pharmacy Technician registration with the Minnesota State Board of Pharmacy.
For Minnesota Board of Pharmacy registrations on or after January 1, 2013, a certificate of completion from an MNBOP-approved employer-based or vocational/technical training program.

Responsibilities

Verify insurance benefits, analyze payer policies, identify potential access issues, and remove barriers to care across Fairview Pharmacy Services.
Resolve access issues with payers and provide information and expertise to other departments.
Assess patients’ payer source and clinical information to identify an appropriate site of care and coordinate with staff as appropriate.
Screen patients for financial assistance eligibility by gathering financial information, including income, assets, and estimated service charges, as appropriate.
Support pharmacy services with revenue cycle requests related to coding and billing for infusions and clinic-administered medications.
Maintain knowledge of payer requirements and general admitting practices, including use of online verification applications, and provide initial and ongoing training.
Coordinate and authorize payer-mandated white bagging when required by Minnesota state law.
Apply third-party and Medicare/Medicaid regulations and billing guidelines related to pharmacy and medical benefits, including coordination of benefits and copay assistance.
Coordinate prior authorization and access with outside facilities as needed for MHFV providers.
Research other payment programs and negotiate with providers and third-party payers for coverage or exceptions.
Partner with international and self-pay patients regarding financial or service needs related to pharmacy care.
Provide financial counseling and support during treatment, communicate financial assistance options, and answer questions to ensure patients understand their benefits.
Explain patient charges and medical and pharmacy insurance benefits, including expectations for financial responsibility related to access issues.
Advise patients on alternative access routes when Fairview Pharmacy Services cannot provide service, such as limited distribution, payer carve-outs, or benefit design limitations.
Expedite access to high-cost medications by identifying and resolving barriers for clinic care teams, including submitting and following prior authorizations and appeals, pursuing alternate funding for claim appeals, and helping patients with financial assistance for out-of-pocket costs.
Understand the patient journey and available support resources, and use strategies to shape ongoing patient relationships.
Communicate expectations, timing, and process capabilities to pharmacy staff, patients, caregivers, and clinics.
Coordinate drug care with clinics and Fairview Pharmacy Services teams to support seamless transitions and access to high-cost medications.
Meet regularly with clinic staff to build relationships and represent Fairview Pharmacy Services.
Assist care teams with Letters of Medical Necessity and maintain a template library.
Coordinate with care teams on high-level appeals across Fairview Pharmacy Services, including Court of Appeals matters.
Advocate for ambulatory pharmacy services, including specialty, home infusion, compounding, and acute care pharmacy, and explain services offered across Fairview Pharmacy Services locations.
Use reports and data across Fairview Pharmacy Services to identify and implement process changes that improve communication and service among patients, providers, and pharmacy teams and support accurate, timely care.
Support Pharmacy Services and the organization in onboarding high-cost new drug therapies to ensure appropriate patient access and team education.
Teach and train pharmacy staff on broad access issues as a Pharmacy Services access subject matter and situational expert and educational resource.
Serve as a resource to affiliations, staff, and physicians regarding Fairview Pharmacy Services, coordinating services through timely and effective communication.
Build relationships with industry representatives and reimbursement managers to stay current on financial assistance programs.
Identify and escalate issues that are beyond the role’s scope.