JOB DESCRIPTION

Description

Position Summary

The team requires a highly motivated, energetic, team player who is responsible for completing necessary functions to ensure optimal intake and reimbursement for high cost and infusion medications for patients receiving care within the UH Meds enterprise of pharmacy operations.

The Pharmacy Support Liaison must have a strong knowledge of Medicare and Medicaid regulations and commercial insurer criteria for payment of home care services.

Additionally, they will be responsible for verification of insurance, and benefits for Home Care Pharmacy services inclusive of new referrals and therapy changes, adjudication of claims and obtaining the initial authorization for visits from commercial insurers.

This position will work with Home Care RN Coordinators, Pharmacist and other clinical teams to ensure that required clinical documentation is obtained prior to acceptance onto service.

They will also enters pertinent information into the pharmacy and / or certified home health software systems used by the enterprise.

The position works closely with and is a supportive role to the Transition Specialist, Clinic Based / Distributional Pharmacists, Central Intake RN’s and the Document Control Specialist.

Essential Functions

• Access care management documentation systems for data entry and to support the existing programs and processes by collecting information, utilizing appropriate department policies, procedures and guidelines specific to members’ eligibility, benefits and contracts.
• Perform intake of service requests from providers or members received electronically, or via telephone or fax.
• Triage and respond to incoming phone calls providing information and assistance to meet the caller’s needs.
• Authorize service(s) based on plan design or clinical guidelines in accordance with the department policies / guidelines.
• Improve patient service experience and maximize pharmacy revenue through provision of prior authorization services on behalf of patients needing high cost medications.
• Conduct patient insurance, benefits and financial investigation and verification by directly communicating with patients.

Complete initial and renewal prior authorization forms, negotiate authorization status with insurers, track status of medication approval, and when necessary, alert stakeholders of denials or nonresponse.

Identify patient needs and ensure coverage of medication on their insurance plan through benefits investigation. If not covered, obtain necessary information from medical record, patient, and provider to enable justification for Patient Assistance program or copay assistance.

Contact patients to provide information related to these resources.

Facilitate enrollment of patients in patient assistance programs and collaborate with social services and case management on patient assistance.

Assist pharmacists with preparing letters of medical necessity and coordinating peer-to-peer conferences.

Expedite pharmacy workflow and enhance patient care by preventing therapy interruptions due to insurance issues in conjunction with pharmacists, physicians, transition care coordinators, nursing, and clinic staff.

Communicate and collaborate regarding patient therapy interruptions, additional therapy monitoring requirements, and alternative care delivery setting options.

• Assist with the development and implementation of policies and procedures to ensure reimbursement of high cost medications.
• Participate in revenue cycle committees to help identify causes of denied claims and develop workflow solutions to optimize revenue capture
• Other responsibilities will be assigned based on departmental and operational needs
• Facilitate staff training and competency, education and practice advancement

Train new staff members

Maintain a training and competency program for all staff that meets accreditation standards

Coordinate with Pharmacy leadership to develop training experiences / competencies

Represent the department at hospital meetings, committees, and events as requested

• Patient Engagement Tele pharmacy Support :
• Answer incoming calls and respond to electronic communications
• Assist health care providers and patients by greeting them by phone; answering questions and requests; referring inquiries to the site pharmacist(s) as needed.
• Handle customer inquiries both telephonically and by email
• Research required information using available resources
• Manage and resolve customer complaints

Required For All Jobs

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

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QUALIFICATIONS

Qualifications

Qualifications

Education

• High School Equivalent / GED . Required and
• Bachelor’s Degree in health care related or business field Preferred

Work Experience

• 3 years Strong clinical background experience in a medical office or other health care setting Required
• CPHT Certified Pharmacy Technician highly preferred

Knowledge, Skills, & Abilities

• Knowledge of medical terminology and ICD9, ICD10, CPT, and DRG codes Required
• Knowledge of third-party insurance billing practices, federal and state regulations with regard to billing and reimbursement, internal billing structure, and billing procedures Required
• Experience with patient assistance programs Required

Physical Demands

• Standing Occasionally
• Walking Occasionally
• Sitting Constantly
• Lifting Rarely 20 lbs
• Carrying Rarely 20 lbs
• Pushing Rarely 20 lbs
• Pulling Rarely 20 lbs
• Climbing Rarely 20 lbs
• Balancing Rarely
• Stooping Rarely
• Kneeling Rarely
• Crouching Rarely
• Crawling Rarely
• Reaching Rarely
• Handling Occasionally
• Grasping Occasionally
• Feeling Rarely
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Frequently
• Eye / Hand / Foot Coordination Frequently

LOCATION

University Hospitals is a national leader in healthcare that takes pride in calling North-East, Ohio home. With more than 150 locations throughout Cleveland and the surrounding metropolitan areas, UH provides unique opportunities to deliver world-class care in the communities where our employees live, work, and play.

Last updated : 2024-04-27