Lead Pharmacy Business Coordinator - Infusion

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Responsible for assisting with the training of new employees hired into the department or organization, as well as involvement in departmental and/or organizational committees for process improvement, operational efficiency, and financial accountability. Also, 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. Knowledge will include at minimum, all aspects of payer relations, claims adjudication, contractual claims processing and general reimbursement procedures. Provides customer support and resolves problems that may arise because of customer inquiries.

Supports the work of the department by completing reports and performing clerical duties as needed. Responsible for performing pharmacy related functions in compliance, outcomes, operations, and clinical areas with departmental policies and procedures that provide optimal pharmaceutical care.

• 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 documents review of meeting minutes.
• Participates in quality activities as assigned by department leadership to meet quality objectives.
• 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.
• Negotiating pharmacy reimbursement rates and language with payers, establish strong relationships with senior staff members at the payer/insurance organization and managing/maintaining pharmacy contracts.
• Maintains database that lists all pharmacy contracts that are currently on file (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, over payments, and…