Pharmacy Access Rep III - Community Pharmacy

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

601 Elmwood Ave, Rochester, New York, United States of America, 14642

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

500160 Pharmacy SMH

Work Shift:

UR - Day (United States of America)

Range:

UR URCA 206 H

Compensation Range:

$21.71 - $29.31

The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

GENERAL PURPOSE
Responsible for the overall management of drug access for high-cost specialty and restricted access drugs in assigned clinics. Collaborates with clinical staff to acquire prior authorization for relevant providers, investigates benefits, enrolls patients in appropriate patient assistance programs, manages the vendor payment process for the assistance programs, and collaborates with patient financial services to ensure accurate billing for the patient self-pay obligation. Organizes and plans work in order to accomplish daily work requirements.

ESSENTIAL FUNCTIONS

• Maintains knowledge of the current policies of the major payers for the relevant clinic-administered drugs that require prior authorization (PA) and is responsible for working with the clinic providers, nurses and other patient care staff to ensure all required elements of the policy are applicable in advance of requesting PA.
• Take primary responsibility for submitting PA requests to payers for clinic-administered drugs and managing the submission of any supplemental information that is requested.
• Review all denials for PA to determine the reason the request was denied and prepares a response to the payer with necessary additional information.
• If the denial management needs to involve other clinic staff or providers, the required individuals will be engaged and a summary of all actions taken to date along with supporting documentation will be provided.
• Notifies the relevant provider and provides the physician with needed documentation and summary of actions taken to date, if a letter of medical necessity is needed or if physician-to-medical director conversation is needed for approval outside of the payer policy.
• Documents all PAs in the appropriate location within the electronic medical record, including the PA number and dates of approval.
• Tracks all PAs to ensure they are renewed on a timely basis to prevent interruptions or delays in treatment.
• Remains up to date on all potential patient assistance programs (PAP) relevant to the high-cost, clinic-administered drugs used in the assigned clinic(s).
• Prospectively evaluates every patient receiving high-cost, clinic-administered drug therapy for potential participation in PAPs and identifies the best option(s) for the patient given overall circumstances.
• Meets with and interviews the patient and/or family to obtain necessary information, including income information and other personal details, and present PAP options to the patient/family when there are multiple options.
• Enrolls patients in PAPs using the mechanisms required for each program and follows-through to ensure PAP is approved and properly documented in the electronic medical record.
• Submits all required documentation to the PAP throughout the duration of treatment to ensure payment for each dose administered and continued coverage for the maximum amount of assistance available.
• For governmental payers where PAPs may represent no-cost drug that is provided from an outside pharmacy/distributor, responsible for managing the patient specific inventory so it is available for administration on treatment days.
• Ensures documentation is appropriate to suppress any patient charge for the medication itself. As needed, meets or discusses the status of PAP eligibility and changes with the patient and/or family.
• Serves as a general resource available to patients, providers and other clinic staff about PAPs.
• Tracks all payments received from PAPs and provides monthly, quarterly and annual reports summarizi