Pharmacy Business Coordinator - Home Infusion

About the role

This position is responsible for conducting payer discussions, in-house financial audits, payer performance compliance, prepayment claims audit, CMS CERT audits, CMS Fraud, Waste, & Abuse audits, and auditing 3rd party payer compliance. They must maintain knowledge of revenue cycle operations, third party reimbursement procedures & regulations, payer relations, claims adjudication, contractual claims processing, medical terminology, and an understanding of the 340B Drug Discount Program.

Responsibilities

• Drafts various correspondence letters and sends to referral source when necessary.
• Gathers and documents demographics, insurance information, needs assessment, and other data as needed.
• Provides information and answers to patient/caregiver questions and refers to clinician when appropriate or requested.
• Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.
• Enters pre-registration using the comprehensive data elements into the registration/billing.
• Contacts insurance company or employer to determine eligibility and benefits for requested services.
• Performs medical necessity screening as required by third party payers.
• Identifies managed care admission/treatment requirements and assures the requirements are met to guarantee payment of the account.
• Initiates charge anticipation calculations.
• Accurately identifies anticipated charges to assure identification of anticipated self-pay portions.
• Communicates with the patient the anticipated self-pay portion (co-payments/deductibles/co-insurance) and establishes payment arrangements based on the Financial Policy and documents the financial resolution in the registration/billing systems.
• Maintains current knowledge of major payor payment provisions and regulations.
• Maintains registration accuracy threshold of 98% as identified in audit processing.
• Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.
• Attends departmental meetings and/ or documents review of meeting minutes.
• Participates in quality activities as assigned by Specialty Pharmacist Manager.
• Participates in performance improvement (i.e. follows established work systems, identifies deviations or deficiencies in standards/systems/processes and communicates problems to coordinator or manager).
• Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.
• Communicates problems hindering workflow to management in a timely manner.
• Demonstrates the knowledge and skills necessary to communicate to the infant, pediatric, adolescent, adult and/or geriatric patient per the established age-specific education/standard.
• Assesses all self-pay patients for potential public assistance through registration/billing systems.
• Obtains commitment to pay from patients that do not meet requirements for public assistance or full charity write off.
• Maintains database that lists all pharmacy contracts that are currently on file. (both Retail and Specialty)
• (both Retail and Specialty)
• Performs routine contract reconciliation at prescription level detail.
• Reviews all pharmacy payer (Commercial & Government) contract terms, identify and report areas of concern or changes in contracts that could have a negative impact on the organization.
• Responsible for periodically reviewing pharmacy contracts (at least annually) for updates or changes in contract language as well as seeking higher reimbursement rates.
• Facilitates discussions with insurance companies to resolve payment issues and to identify payment, overpayments, and underpayments.
• Conducts claims extracts and payer payment evaluations to perform contract compliance tests.
• Organizes meeting materials and attends various organization meetings as needed.
• Manages customer service related phone calls or written requests related to pharmacy contracting issues and ensure timely resolution.

Qualifications

• Minimum Qualifications: Bachelor’s Degree in healthcare administration, business, finance, or related field AND one (1) year of business OR healthcare-related experience OR High School Diploma or Equivalent AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND two (2) years of healthcare-related experience OR Associate’s Degree AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND one (1) year of healthcare-related experience
• Preferred Qualifications: PTCB Advanced Pharmacy Technician Certificate. Experience Three (3) years working in a specialty pharmacy.

Skills and Abilities

• Must be able to use computers and software applications.
• Knowledge of drugs, drugs dosing, side effects, indications, contraindications and proper administration preferred.
• Knowledge of rules, policies and regulations related to the disbursal of pharmaceutical drugs preferred.
• Knowledge of clinical procedures or operations.
• Must be able to work with multiple demands.
• Must be able to work accurately, efficiently, and safely in a fast-paced environment.
• Must be polite and respectful when communicating with staff, physicians, patients and families.
• Must approach interpersonal relations in a positive manner.
• Must demonstrate flexibility to meet the needs of department or hospital in regard to changes in work volume, planned change, scheduling changes and emergency call-backs (i.e. weather or disaster).
• Must be able to communicate effectively verbally and in writing and place high emphasis on customer service.