Pharmacy Access Rep III - Community Pharmacy

ESSENTIAL FUNCTIONS

• Maintains knowledge of the current policies of the major payers for the relevant clinic-administered drugs that require prior authorization (PA) and is responsible for working with the clinic providers, nurses and other patient care staff to ensure all required elements of the policy are applicable in advance of requesting PA.
• Take primary responsibility for submitting PA requests to payers for clinic-administered drugs and managing the submission of any supplemental information that is requested.
• Review all denials for PA to determine the reason the request was denied and prepares a response to the payer with necessary additional information.
• If the denial management needs to involve other clinic staff or providers, the required individuals will be engaged and a summary of all actions taken to date along with supporting documentation will be provided.
• Notifies the relevant provider and provides the physician with needed documentation and summary of actions taken to date, if a letter of medical necessity is needed or if physician-to-medical director conversation is needed for approval outside of the payer policy.
• Documents all PAs in the appropriate location within the electronic medical record, including the PA number and dates of approval.
• Tracks all PAs to ensure they are renewed on a timely basis to prevent interruptions or delays in treatment.
• Remains up to date on all potential patient assistance programs (PAP) relevant to the high-cost, clinic-administered drugs used in the assigned clinic(s).
• Prospectively evaluates every patient receiving high-cost, clinic-administered drug therapy for potential participation in PAPs and identifies the best option(s) for the patient given overall circumstances.
• Meets with and interviews the patient and/or family to obtain necessary information, including income information and other personal details, and present PAP options to the patient/family when there are multiple options.
• Enrolls patients in PAPs using the mechanisms required for each program and follows-through to ensure PAP is approved and properly documented in the electronic medical record.
• Submits all required documentation to the PAP throughout the duration of treatment to ensure payment for each dose administered and continued coverage for the maximum amount of assistance available.
• For governmental payers where PAPs may represent no-cost drug that is provided from an outside pharmacy/distributor, responsible for managing the patient specific inventory so it is available for administration on treatment days.
• Ensures documentation is appropriate to suppress any patient charge for the medication itself. As needed, meets or discusses the status of PAP eligibility and changes with the patient and/or family.
• Serves as a general resource available to patients, providers and other clinic staff about PAPs.
• Tracks all payments received from PAPs and provides monthly, quarterly and annual reports summarizing the patient out-of-pocket savings attributed to PAP payments received.
• Tracks all no-cost drug received for patients with governmental payers and quantifies the savings realized by the patient or institution on a monthly, quarterly and annual basis.
• Conducts a benefits investigation for high-cost, clinic administered drugs and discusses the patient obligation for treatment with the patient and/or family.
• Understands and manages the payment process specific to each PAP and ensures payments are properly applied to the correct patient and correct patient encounter.
• If needed, ensures the PAP is set-up within the electronic medical record revenue application as a secondary or tertiary payer.
• Works collaboratively with Patient Financial Services to ensure patient bills are held pending payment from the PAP and the final bill sent to the patient accurately reflects the patient’s obligation after payment is received from the PAP.
• Acts professionally, courteously and diligently in all interactions with staff and patients/families.
• Collects patient satisfaction survey data on a regular basis to assess the goal of high patient satisfaction and high overall drug management process.

Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• Associate's degree in medical, Secretarial or related field and 3 years of relevant experience required
• Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

• Capable of working independently with minimum supervision required
• Strong communication skills, problem-solving abilities, and a professional presentation required
• Demonstrated customer relations skills required
• Medical terminology, experience with medical/surgical scheduling software, and electronic medical records preferred

LICENSES AND CERTIFICATIONS

• PHAR-C - Certified Pharmacy Tech Certified pharmacy technician (PTCB) upon hire preferred