Program Manager - Pharmacy

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

About Duke HomeCare & Hospice

 

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

 

Job Title: Program Manager - Pharmacy

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

 

JOB SUMMARY:  The Infusion Patient Eligibility Program Manager will serve as the primary resource liaison to ensure infusion patients are set up with proper required documentation, timely approvals, and perform troubleshooting for a streamlined transition from all care providers within Duke Health to continue home care proactively preventing financial risk and delayed patient care.  Responsible for primary communication with intra- and interdepartmental customers.

 

 MAJOR JOB RESPONSIBILITIES:

• Manage for the infusion department finalizing authorizations process and coordination between referral center, finance, and provider offices for timely, accurate, and streamlined approvals.
• Monitor and serve as primary resource for questions related to verification, authorization, and finance affecting approvals and billing.
• Facilitate and participate in meetings to address challenges and obstacles in the onboarding process for specialty patients, and implement process improvements.
• Oversee and support the verification and authorization procedures for specialty patients.
• Supervise the authorization queue for new and refill requests of specialty patients.
• Assist and review rejected pharmacy claims for resolution.
• Conduct random chart audits for new referrals and existing patients to monitor for documentation accuracy.
• Evaluate the timeline from receiving specialty referrals to patient onboarding, and identify opportunities for improving turnaround times.
• Review policy updates and health insurance criteria to enhance the onboarding process for specialty patients.
• Liaise with providers' offices and check patient portals for additional documentation required for home infusion or health insurance reviews.
• Coordinate with home health agencies to obtain necessary nursing notes and additional documentation for home infusion.
• Ensure all required documentation and authorizations are secured prior to patient onboarding to facilitate initial clean claim processing by the billing department.
• Monitor claims on hold and gather missing information to enable the billing department to process claims.
• Track denial reports and obtain necessary documentation for diagnosis-related denials.
• Assist in contacting patients to request updates on their health insurance plans for coordination of benefits.
• Monitor ineligibility reports, check patient portals, and contact patients for updated health insurance information.
• Follow up with various departments, provider offices, referral sources, home health agencies, and patients to obtain missing documentation for the onboarding process.
• Consult with the home infusion legal department to verify and proceed with requests from law firms.
• Obtain and send required documentation for Medicare audits, law firms, and health insurance companies.
• Work with leadership to ensure we are meeting state, federal, and accrediting agency requirements for patient documentation and billing.
• Monitor the National Council for Prescription Drug Programs (NCPDP) pharmacy queue and assist with resolving rejected pharmacy claims.
• Collaborate d