Specialty Pharmacy Financial Access Manager; HSO Specialty Pharmacy

Under direct supervision of the Senior Specialty Clinical Pharmacist Manager, the Specialty Pharmacy Financial Access Manager supervises Financial Access Coordinator staff and interacts with clinical employees on multiple levels, including pharmacists, nurses, medical/clinical staff, Finance personnel, department managers, access services staff, and Billing Assistants.  External contacts may include third party payers, accrediting bodies, insurance /PBM companies, government peer review organizations, accrediting bodies and referring physicians.  The relationships are inherent to the success of this position. The manager is primarily responsible for, but not limited to, oversight of staff responsible for the prompt attention to prior authorization of specialty medications, support of medical staff, assistance in obtaining financial support for patients, and timely communication with medical providers, including mail correspondence, messaging, telephone correspondence and EHR documentation.

1.    Organizes the duties of subordinate technical and clerical personnel, including less experienced Specialty Financial Pharmacy Access Coordinators, and billers.
2.    Maintains thorough documentation on all authorization requests, prescription verifications and other data by facility.
3.    Supports managers and directors in the training and mentoring of new pharmacy personnel; nurtures a teamwork environment.
4.    Periodically meets with and manages vendors and pharmaceutical manufacturers.
5.    Organizes and presents reports and analytics as requested.
6.    Reviews and evaluates outpatient prescription medications and determines feasibility of processing through patient and payer-preferred specialty pharmacy and, if not, coordinates service with the correct pharmacy group.  
7.    Obtains prior authorizations from intermediaries and payers, including managed care companies, insurance companies or others as appropriate. Ensures completion of activities that maximize revenue capture for high-cost medications.
8.    Facilitates a high level of customer service by the completion of applications, including those for the Patient Assistance Program (PAP) and co-pay assistance.
9.    Interacts with medical and professional staff on a case by case basis to obtain appropriate clinical documentation to ensure accurate indications in the patient’s medical record before completion of third party authorization.  This may include contacting referring physicians for information.
10.    Communicates with appropriate individuals (i.e., patient, providers, and pharmacy staff) regarding outcomes of prior authorizations and responds to complex questions from third party payers and clinical staff regarding medication-related issues and reimbursement.
11.    Adjudicates approved prescriptions through the pharmacy software system or begins the appeal process for denied prescriptions.
12.    Processes PAP (Patient Assistance Program) requests.  Documents actions taken, runs weekly reports, keeps open lines of communication by facilitating between pharmacy, other healthcare professions, the patient, medication manufacturers and third party payers.
13.    Runs Pharmacy benefit checks at the providers’ requests; periodically performs software tests for proper functionality to ensure coverage for specific medications.
14.    Maintains compliance with all pertinent regulations and laws (HIPAA, Board of Pharmacy, etc).
15.    Oversees eligibility and enrollment in MS PAP program.
16.    Processes payroll for Financial Access Coordinator team
17.    Conducts regular audits and annual performance evaluations of Financial Access Coordinators to ensure compliance with established policies and procedures.
18.    Develops and updates workflow processes to optimize efficiency within the specialty pharmacy.
19.    Other duties as assigned.

• PTCB certification required
• NY BOP license required
• Associate or bachelor’s degree preferred
• 3+ years of retail pharmacy technician experience or related health care administrative, and a strong familiarity with the prior authorization process preferred.  Working knowledge of third party payer plans and how they are processed, of medication reimbursement, including the prior authorization process, proficiency in the procurement of financial assistance for patients with government-sponsored health plans including Medicare, Medicaid and TriCare.

Preferred:

• 3 years of health care related billing and benefits investigation 
• 1 year of retail pharmacy experience 
• 1 year of PBM payer operations 
• 1 year of hospital/institutional pharmacy 

Compensation Statement

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The sal