Pharmacy Reimbursement Specialist - Oncology

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:

High Cost Oncology Drug Authorizations

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.

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Key Responsibilities

• Clarify and trend pharmaceutical denials and underpayments of the highest cost drugs and other drugs.
• Utilize data from finance and pharmacy systems to determine reimbursement rates for pharmaceuticals for various patient care settings.
• Evaluate actual reimbursement compared to defined contractual reimbursement rates for specific drugs/procedures.
• Provide trending on reimbursement and information on areas for focus to maximize reimbursement.
• Maintain data in appropriate database to facilitate evaluation and presentation of data.
• Evaluate 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, define areas for focus to maximize reimbursement and present plan to above departments.
• Maintain list of potential opportunities for reimbursement and contracting based on proactive review of data.
• Work collaboratively to develop programs and procedures to maximize reimbursement of pharmaceuticals.
• Facilitate process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals.
• Work with pharmacy staff and finance to evaluate reimbursement of new drugs and propose necessary procedures to maximize reimbursement.
• Document enhanced reimbursement from developed programs and trend success of programs.
• Utilize databases maintained to provide documentation to support the effectiveness of the reimbursement program. Assist with regulatory compliance related to safe medication use with program, operational, regulatory bodies (JCAHO, ASHP, state and federal regulations, Leapfrog, etc.), and institutional policies and procedures.
• Provide written monthly update on activities and financial impact of program to enhance reimbursement.
• Assist billing manager and document regulatory compliance related to billing of pharmaceuticals and work to correct any variances.
• Work with Patient Assistance Programs (PAP) to include identifying new opportunities, document receipt of funds and provide proper adjustment of patient accounting accounts.
• Collaborate with pharmacy, finance, contracts and patient accounting to identify ongoing opportunities to expand the PAP to reduce drug cost.
• Document savings from the PAP and provide a monthly report trending the savings from the program.
• Provide recommendations to pharmacy administration for input into hospital contracting for enhanced reimbursement.
• Maintain proper resources and contacts to understand the contractual reimbursement of pharmaceuticals.
• Maintain documentation on any issues with contractual reimbursement including the financial impact for review by pharmacy, finance and contracting.
• Contribute to the continuing education of pharmacy on the reimbursement of pharmaceuticals and the contractual trends for reimbursement.

 

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At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits,