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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. 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 as a result 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 with departmental policies and procedures that provide optimal pharmaceutical care.
Additionally, the Pharmacy Business Coordinator may be responsible for securing registration data based upon comprehensive data elements, financial education/counseling, insurance verification, provision of clinical information for pre-certification, authorization and third party claims management. Interviews patient and arranges alternate methods of payment. Ability to calculate patient co- payments and deductibles based upon benefits processing.
MINIMUM QUALIFICATIONS:
EDUCATION, EXPERIENCE, CERTIFICATION, AND/OR LICENSURE:
1. 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:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. PTCB Advanced Pharmacy Technician Certificate.
EXPERIENCE:
1. Three(3)yearsworkinginaspecialtypharmacy.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Drafts various correspondence letters and sends to referral source when necessary.
2. Gathers and documents demographics, insurance information, needs assessment, and other data as needed.
3. Provides information and answers to patient/caregiver questions and refers to clinician when appropriate or requested.
4. Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.
5. Enters pre-registration using the comprehensive data elements into the registration/billing.
6. Contacts insurance company or employer to determine eligibility and benefits for requested services.
7. Performs medical necessity screening as required by third party payers.
8. Identifies managed care admission/treatment requirements and assures the requirements are met to guarantee payment of the account.
9. Initiates charge anticipation calculations. Accurately identifies anticipated charges to assure identification of anticipated
self-pay portions.
10. 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.
11. Maintains current knowledge of major payor payment provisions and regulations.
12. Maintains registration accuracy threshold of 98% as identified in audit processing.
13. Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.
14. Attends departmental meetings and/ or documents review of meeting minutes.
15. Participates in quality activities as assigned by Specialty Pharmacist Manager.
16. 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).
17. Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers and the
public regarding demographic/clinical/financial information.
18. Communicates problems hindering workflow to management in a timely manner.
19. 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.
20. Assesses all self-pay patients for potential public assistance through registration/billing systems.
21. Obtains commitment to pay from patients that do not meet requirements for public assistance or full charity write off.
22. Maintains database that lists all pharmacy contracts that are currently on file. ( both Retail and Specialty)
23. Performs routine contract reconciliation at prescription level detail.
24. 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.
25. Responsible for periodically reviewing pharmacy contracts (at least annually) for updates or changes in contract language as well as seeking higher reimbursement rates.
26. Facilitates discussions with insurance companies to resolve payment issues and to identify payment, overpayments, and underpayments.
27. Conducts claims extracts and payer payment evaluations to perform contract compliance tests.
28. Organizes meeting materials and attends various organization meetings as needed.
29. Manages customer service related phone calls or written requests related to pharmacy contracting issues and ensure timely resolution.
30. Comprehensive understanding of the 340B Drug Discount program in addition to assisting with compliance of the 340B Drug Discount Program.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Prolonged sitting.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS AND ABILITIES:
1. Must be able to use computers and software applications.
2. Knowledge of drugs, drugs dosing, side effects, indications, contraindications and proper administration preferred.
3. Knowledge of rules, policies and regulations related to the disbursal of pharmaceutical drugs preferred.
4. Knowledge of clinical procedures or operations.
5. Must be able to work with multiple demands.
6. Must be able to work accurately, efficiently, and safely in a fast-paced environment.
7. Must be polite and respectful when communicating with staff, physicians, patients and families. Must approach interpersonal relations in a positive manner.
8. 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).
9. Must be able to communicate effectively verbally and in writing and place high emphasis on customer service.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Non-Exempt)
Company:
WVUH West Virginia University Hospitals
Cost Center:
255 WVUH Home Infusion
Address:
3040 University AveMorgantownWest Virginia
Equal Opportunity Employer
West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.
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