Pharmacy Reimbursement Specialist 2 - Population Health

Vanderbilt University Medical Center•Nashville, TN

1d•Hybrid

About The Position

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. This position includes working with Medicare Advantage Plans and patient adherence. Position will be located onsite for initial training and onboarding. A hybrid schedule is available after training and onboarding have been successfully completed.

Requirements

Must have 2 years of relevant experience.
Must have a TN Pharmacy Technician license.
Must be a Certified Pharmacy Technician through either PTCB or NHA in order to be considered.

Nice To Haves

Retail/outpatient pharmacy experience and customer service experience are preferred.

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.