Job Description

General Summary of Position
Collaborates with providers and revenue cycle team to ensure safe and effective use of specialty medications at infusion centers by reviewing the order and evaluating clinical guidelines, formulary protocols, payor preference, and appropriate clinical documentation aligning to the medical necessity to obtain authorizations promptly. With clinical knowledge, serves as a liaison between healthcare providers and the revenue cycle team in improving efficiencies and reducing denials.

Primary Duties and Responsibilities

• Conducts medication order review according to the approved guidelines for indication, dosage regimen design, and approved formulary.
• Validates the appropriate clinical documentation against the medical necessity and develops initiatives with providers to align the documentation with the payor requirements.
• Identifies, analyzes, and researches frequent root causes of denials and develops corrective action plans in collaboration with the revenue cycle team and providers
• Researches denied cases and assembles appeals in collaboration with the provider.
• Serves as a liaison between the central revenue cycle authorization team and clinical departments to enhance providers' awareness of improving efficiencies and reducing denials.
• Collaborates with the central revenue cycle team in quality improvement initiatives.
• Actively participates and contributes to P&T committee meetings in developing system formulary.
• Develops and sustains routine communication channels with the revenue cycle, billing, and information systems departments and ensures clarity, consistency, and accuracy around the pharmacy reimbursement and revenue cycle.
• Maintains current knowledge of payor and regulatory guidelines for medical insurance claims processing, medical terminology, CPT, HCPCS, and ICD-10 codes in obtaining insurance authorization and reimbursement.
• Responsible for prioritizing and developing efficiencies in managing work queues.

Minimum Qualifications
Education

• Doctoral degree in Pharmacy required

Experience

• 3-4 years Pharmacist experience in a hospital setting required
• 3-4 years Ambulatory infusion pharmacy experience is highly preferred

Knowledge, Skills, and Abilities

• Excellent problem-solving skills and ability to exercise independent judgment
• Strong verbal and written communication skills
• Ability to work with individuals from multiple departments
• Knowledge of medical billing and revenue cycle activities
• Clinical knowledge in oncology and other specialty diseases

This position has a hiring range of $118,331 - $230,172

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