Pharmacy Reimbursement Specialist - Population Health

Discover Vanderbilt University Medical Center:  Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health is committed to an environment where everyone has the chance to thrive and where your uniqueness is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

Pop Health Rx Support Team

Job Summary:

Evaluates reimbursement of medications provided to inpatients, clinic patients and patients receiving prescriptions through the outpatient pharmacy network. Works with multidisciplinary groups to develop proper procedures and programs to maximize reimbursement. Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals. Assists with maintaining drug and payer data files in the dispensing system. Works with dispensing staff and/or Payor Help Desk Staff to troubleshoot issues with medication claims and, when needed, editing/resubmitting claims in the OP dispensing system.

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Position Highlights

• The Pharmacy Reimbursement Specialist will practice in the Office of Population Health and the Vanderbilt Health Affiliated Network, primarily supporting primary care clinics.
• Provides support to team pharmacists, patients, clinicians, and the care management team to ensure effective, safe, and cost-effective drug therapy in a population health model.
• Supports the pharmacist with implementing the patient’s care plan, such as navigating insurance benefits and assisting with provider communication.
• Chart review and clinical documentation responsibilities.
• Pharmacy benefit navigation including test claims and prior authorizations.
• Communicating with patients, providers and colleagues via phone and messages.
• Addressing patient challenges regarding adherence and cost.
• Supporting quality improvement initiatives including data management, patient stratification, patient onboarding, and collaboration.
• Position will be located onsite for initial training and onboarding.
• Hybrid schedule available after training and onboarding have been successfully completed.
• Monday - Friday. No weekends. No holidays.
• Options for (4) 10-hour shifts or (5) 8-hour shifts.
• Must have 2 years of relevant experience.
• Must have a TN Pharmacy Technician license.
• Must be a Certified Pharmacy Technician through either PTCB or NHA in order to be considered.
• Retail/outpatient pharmacy experience and customer service experience are preferred.

Key Responsibilities

• Clarify and trend pharmaceutical denials and underpayments of the highest cost drugs and other drugs.
• Utilizes data from finance and pharmacy systems to determine reimbursement rates for pharmaceuticals for various patient care settings.
• Evaluates actual reimbursement compared to defined contractual reimbursement rates for specific drugs/procedures.
• Provides trending on reimbursement and information on areas for focus to maximize reimbursement.
• Maintains data in appropriate database to facilitate evaluation and presentation of data.
• Evaluates data enabling the identification of trends by multiple variables.
• Work with patient accounting, finance, contracts and pharmacy to develop strategy for improved reimbursement.
• Utilizing data collected, defines areas for focus to maximize reimbursement and presents plan to above departments.
• Maintains list of potential opportunities for reimbursement and contracting based on proactive review of data.
• Works collaboratively to develop programs and procedures to maximize reimbursement of pharmaceuticals.
• Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals.
• Works with pharmacy staff and finance to evaluate reimbursement of new drugs and proposes necessary procedures to maximize reimbursement.
• Document enhanced reimbursement from developed programs and trend success of programs.
• Utilizing databases maintained to p