Specialty Pharmacy Financial Access Coordinator, Lead; Mount Sinai Health System

Mount Sinai Health System•New York, NY

13d

About The Position

Under direct supervision of the Director of Specialty Pharmacy, the Specialty Pharmacy Manager and the Specialty Pharmacy Clinical Liaison, the Specialty Pharmacy Access Coordinator Lead supervises Financial Access Coordinator staff and interacts with clinical employees on multiple levels, including pharmacists, nurses, medical/clinical staff, Finance personnel, department managers, access services staff, and Billing Assistants. External contacts may include third party payers, accrediting bodies, insurance /PBM companies, government peer review organizations, accrediting bodies,external partners, and referring physicians. The relationships are inherent to the success of this position. The Lead is primarily responsible for, but not limited to, oversight of staff responsible for the prompt attention to prior authorization of specialty medications, oversight of the quality of work done in key department systems, support of medical staff, assistance in obtaining financial support for patients, and timely communication with medical providers, including mail correspondence, messaging, telephone correspondence and EHR documentation.

Requirements

Associates degree (Bachelor’s degree preferred)
3+ years of retail pharmacy technician experience or related health care administrative, and a strong familiarity with the prior authorization process preferred.
Working knowledge of third party payer plans and how they are processed, of medication reimbursement, including the prior authorization process, proficiency in the procurement of financial assistance for patients with government-sponsored health plans including Medicare , Medicaid and TriCare.

Nice To Haves

3 years of health care related billing and benefits investigation
1 year of retail pharmacy experience
1 year of PBM payer operations
1 year of hospital/institutional pharmacy

Responsibilities

Organizes the duties of subordinate technical and clerical personnel, including less experienced Specialty Financial Pharmacy Access Coordinators, and billers.
Maintains thorough documentation on all authorization requests, prescription verifications and other data by facility.
Supports supervising Pharmacists.
Supports manages and directors in the training and mentoring of new pharmacy personnel; nurtures a teamwork environment.
Periodically meets with and manages vendors and pharmaceutical manufacturers.
Supports, facilitates, and reviews departmental projects, initiatives, and partner programs
Works with department pharmacists and administrators to design, administer, and support quality assurance and related tasks
Accesses and reviews work in all key department systems (dispense, clinical management, EMR)
Organizes and presents reports and analytics as requested.
Reviews and evaluates outpatient take-home prescriptions and determines feasibility of processing through patient and payer-preferred specialty pharmacy and, if not, coordinates service with the correct pharmacy group.
Obtains prior authorizations from intermediaries and payers, including managed care companies, insurance companies or others as appropriate. Ensures completion of activities that maximize revenue capture for high-cost medications.
Facilitates a high level of customer service by the completion of applications, including those for the Patient Assistance Program (PAP) and co-pay assistance.
Interacts with medical and professional staff on a case by case basis to obtain appropriate clinical documentation to ensure accurate indications in the patient’s medical record before completion of third party authorization. This may include contacting referring physicians for information.
Communicates with appropriate individuals (i.e., patient, providers, and pharmacy staff) regarding outcomes of prior authorizations and responds to complex questions from third party payers and clinical staff regarding medication-related issues and reimbursement.
Adjudicates approved prescriptions through the pharmacy software system or begins the appeal process for denied prescriptions.
Processes PAP (Patient Assistance Program) requests. Documents actions taken, runs weekly reports, keeps open lines of communication by facilitating between pharmacy, other healthcare professions, the patient, medication manufacturers and third party payers.
Runs Pharmacy benefit checks at the providers’ requests; periodically performs software tests for proper functionality to ensure coverage for specific medications.
Maintains compliance with all pertinent regulations and laws (HIPAA, Board of Pharmacy, etc).
Other duties as assigned.