Reimbursement Specialist Senior

VCU Health•Richmond, VA

20d

About The Position

The Reimbursement Specialist Senior serves as an advanced-level specialist, handling the most complex prior authorizations, insurance appeals, and patient assistance cases pertaining to high-cost medications that require prior authorization. This role provides guidance to peers, ensures adherence to compliance and turnaround standards, and acts as a subject matter expert for the Reimbursement Specialist team. Essential Job Statements Manage complex or high-priority prior authorizations and appeals across multiple clinics. Provide guidance and mentorship to Reimbursement Specialists on best practices and workflow efficiencies. Collaborate with providers, nursing staff, and the Patient Assistance Program (PAP) team to ensure accurate and timely access to medications. Conduct benefit investigations and gather supporting clinical documentation for challenging cases. Track and analyze Patient Assistance (PA) metrics, approvals, and denials to identify trends and improvement opportunities. Assist in training new team members and provide ongoing education to peers. Participate in special projects to improve departmental operations and patient care. Ensure compliance with departmental and health system policies and regulatory requirements. Serve as a point of escalation for complex PA or patient access issues. Support the supervisor in monitoring workload distribution and workflow optimization. Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the Department. Provides assistance to team members. Accepts alternate assignments, as required. Patient Population Not applicable to this position.

Requirements

High School Diploma or equivalent
Minimum of two (2) years of experience as a Reimbursement Specialist or equivalent role
Demonstrated ability to handle complex PAs, appeals, and PAP cases
Strong problem-solving, analytical, and communication skills
Ability to handle multiple priorities in a fast-paced environment
Cultural Responsiveness
Current certification by the Pharmacy Technician Certification Board (PTCB)
Current licensure with the Virginia State Board of Pharmacy

Nice To Haves

Associate’s Degree or higher in Business, Healthcare Administration, or related field
Additional certifications in reimbursement or pharmacy administration a plus
Strong leadership and communication skills
Ability to handle multiple priorities and high-volume workload

Responsibilities

Manage complex or high-priority prior authorizations and appeals across multiple clinics.
Provide guidance and mentorship to Reimbursement Specialists on best practices and workflow efficiencies.
Collaborate with providers, nursing staff, and the Patient Assistance Program (PAP) team to ensure accurate and timely access to medications.
Conduct benefit investigations and gather supporting clinical documentation for challenging cases.
Track and analyze Patient Assistance (PA) metrics, approvals, and denials to identify trends and improvement opportunities.
Assist in training new team members and provide ongoing education to peers.
Participate in special projects to improve departmental operations and patient care.
Ensure compliance with departmental and health system policies and regulatory requirements.
Serve as a point of escalation for complex PA or patient access issues.
Support the supervisor in monitoring workload distribution and workflow optimization.
Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the Department.
Provides assistance to team members.
Accepts alternate assignments, as required.