Pharmacy Access Rep III - Home Infusion

Responsibilities

• Coordinates medication and supplies coverage with referral sources and pharmacy staff to ensure timely financial approval.
• Coordinates and troubleshoots insurance issues with referral sources, pharmacists, physicians, and staff to prevent treatment interruptions.
• Acts as a liaison between home care coordinators, hospital discharge coordinators, home infusion staff and providers to obtain accurate information for home infusion billing.
• Covers medication financial approval, prior to ordering and dispensing with pharmacy for high cost medication.
• Communicates out of pocket costs to patients, care givers or coordinators.
• Identifies coverage gaps and utilizes resources such as Patient Assistance Programs, charity care, specific disease state grants, and social work funds.
• Enrolls patients in PAPs using the needed permission and information, followup to determine the status of the application, and ensure proper documentation of this process.
• Understands and manages the payment process specific to each PAP, and assures that payments are properly accounted for the correct patient and correct patient encounter.
• Serves as a subject matter expert available to patients, providers and other staff about financial assistance resources, including PAPs, grants, foundations, manufacture coupons, and social work.
• Collaborates with social services and case management on patient assistance.

Essential Functions

• Maintains expertise on all insurance coverage related activities for medical benefit and pharmacy benefit plans.
• Retrieves and evaluates incoming home infusion referrals to verify insurance coverage and contract for infusion therapy including drug, supplies or per diem, and nursing when required.
• Obtains benefit information from third party payers to advise patients on their expected out of pocket costs taking into account deductibles, coinsurance, copayments or total charges if services are not covered.
• Determines if home infusion therapy being ordered meets payer requirements for coverage.
• Retrieves and assembles necessary information for insurance coverage qualifications as needed.
• Communicates out of pocket costs to patients, care givers or coordinators.
• Identifies coverage gaps and utilizes resources such as Patient Assistance Programs, charity care, specific disease state grants, and social work funds.
• Enrolls patients in PAPs using the needed permission and information, followup to determine the status of the application, and ensure proper documentation of this process.
• Submits all required documentation to the PAP throughout the duration of treatment to verify payment for each prescription refill is still active.
• Serves as a subject matter expert available to patients, providers and other staff about financial assistance resources, including PAPs, grants, foundations, manufacture coupons, and social work.
• Collaborates with social services and case management on patient assistance.

Compliance and Quality

• Remains professional, courteous and diligent in all interactions with staff and patients/families.
• Obtains high patient and provider satisfaction results.
• Reports errors through hospital error reporting system (RL solutions) and contribute to quality improvement initiatives.
• Affords assistance with prescription audits and ensure timely completion of required patient documentation.
• Coordinate required information for denied claims.
• Participate in payer audits and collect, summarize and send requested information.
• Affords assistance with training of new team members in designated clinical area.

Qualifications

• Complete ASHP accredited training program or equivalent experience as a pharmacy technician, or Certification from a nationally accredited pharmacy technician certification program (Currently PTCB) and maintain ongoing education requirements preferred.