Pharmacy Reimbursement Specialist

Discover Vanderbilt Health: With eight hospitals and over 180 clinics, we are the region’s largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you’ll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.

Organization:

Pharmacy Non-Onc Prior Auth

Job Summary:

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.

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Position Highlights

• Hours are Monday - Friday 8:00am - 4:30pm.
• No weekends and no holidays.
• Responsibilities include obtaining prior authorizations for high-cost medications, calling and following up with insurance, verifying benefits, communicating with providers, nurses and clinics, eligibility for benefits, entering approvals from insurance appropriately, all in a fast-paced and high-volume environment.
• Prior authorization experience with high-cost medications is preferred.
• 1 year of relevant pharmacy experience is required.
• This position has the potential to work remotely after the initial training and onboarding have been successfully completed with the exception of any in office training, etc.

Key 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.

Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.

At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.

Core Accountabilities:

* Organizational Impact: Performs clearly defines tasks and methods described in detail to achieve standardized solutions that impact own performance with regular guidance. * Problem Solving/ Complexity of work: Follows a well established process to solve routine problems where solutions are clearly prescribed. * Breadth of Knowledge: Has basic job knowledge of systems and procedures that are common to own job. * Team Interaction: Individually contributes to the team.

Core Capabilities :

Delivering Excellent Services : Serves Others with Compassion: Invests time to understand the problems, needs of others and how to provide excellent service. Solves Complex Problems: Seeks to understand issues, solves routine problems, and raises proper concerns in a timely manner. Offers Meaningful Advice and Support: Listens carefully to understand the issues and provides accurate information and support. Ensuring High Quality : Performs Excellent Work: Checks work quality before delivery and asks relevant questions to meet quality standards. Ensures Continuous Improvement: Shows eagerness to learn new knowledge, technologies, tools or systems and displays willingness to go above and beyond. Fulfills Safety and Regulatory Requirements: Demonstrates basic knowledge of conditions that affect safety and reports unsafe conditions to the appropriate person or department. Managing Resources Effectively: Demonstrates Accountability: Takes responsibility for completing assigned activities and thinks beyond standard approaches to provide high-quality work/service. Stewards Organizational Resources: Displays understanding of how personal actions will impact departmental resources.Makes Data Driven Decisions: Uses accurate information and good decision making to consistently achieve results on time and without error. Fostering Innovation :Generates New Ideas: Willingly proposes/accepts ideas or initiatives that will impact day-to-day operations by offering suggestions to enhance them. - Applies Technology: Absorbs new technology quickly; understands when to utilize the appropriate tools and procedures to ensure proper course of action. - Adapts to Change: Embraces changes by keeping an open mind to changing plans and incorporates change instructions into own area of work.

Position Qualifications:

Responsibilities:

Certifications:

Work Experience:

Relevant Work Experience

Experience Level:

1 year

Education:

Graduate of an approved discipline specific program

This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth.

Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity.  EOE/Vets/Disabled.