Pharmacy Reimbursement Specialist - Pediatric Outpatient

Vanderbilt University Medical Center•Nashville, TN

1d•Onsite

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 involves rotating between day-to-day operations in the pharmacy and a decentralized location to deliver prescriptions to the appropriate floors/patients as needed. The role utilizes knowledge of the bed board, mobile heartbeat, and prescription filling process to support decentralized operations. It requires communication with patients and families about their prescriptions and coordinating delivery if desired, as well as communicating with nurses, residents, and physicians about medications, discharge times, and potential challenges.

Requirements

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.
Graduate of an approved discipline specific program.

Nice To Haves

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.

Responsibilities

Clarify and trend pharmaceutical denials and underpayments of the highest cost drugs and other drugs.
Utilize data from finance and pharmacy systems to determine reimbursement rates for pharmaceuticals for various patient care settings.
Evaluate actual reimbursement compared to defined contractual reimbursement rates for specific drugs/procedures.
Provide trending on reimbursement and information on areas for focus to maximize reimbursement.
Maintain data in appropriate database to facilitate evaluation and presentation of data.
Evaluate data enabling the identification of trends by multiple variables.
Work with patient accounting, finance, contracts, and pharmacy to develop strategy for improved reimbursement.
Utilize collected data to define areas for focus to maximize reimbursement and present plan to above departments.
Maintain a list of potential opportunities for reimbursement and contracting based on proactive review of data.
Work collaboratively to develop programs and procedures to maximize reimbursement of pharmaceuticals.
Facilitate process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals.
Work with pharmacy staff and finance to evaluate reimbursement of new drugs and propose necessary procedures to maximize reimbursement.
Document enhanced reimbursement from developed programs and trend success of programs.
Utilize maintained databases to provide documentation to support the effectiveness of the reimbursement program.
Assist 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.
Provide written monthly updates on activities and financial impact of programs to enhance reimbursement.
Assist billing manager and document regulatory compliance related to billing of pharmaceuticals and work to correct any variances.
Work with Patient Assistance Programs (PAP) to include identifying new opportunities, documenting receipt of funds, and providing proper adjustment of patient accounting accounts.
Collaborate with pharmacy, finance, contracts, and patient accounting to identify ongoing opportunities to expand the PAP to reduce drug cost.
Document savings from the PAP and provide a monthly report trending the savings from the program.
Provide recommendations to pharmacy administration for input into hospital contracting for enhanced reimbursement.
Maintain proper resources and contacts to understand the contractual reimbursement of pharmaceuticals.
Maintain documentation on any issues with contractual reimbursement including the financial impact for review by pharmacy, finance, and contracting.
Contribute 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.