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General Information


Job title: Pharmacy Resource Spec
Job location: Houston, TX 77030 United States
Requisition code: 8241
Date posted: 03/15/13
Job type: Full-Time

Job Classification

Job Category:Registered Nurse

Job Description

Job description:
Position Title: Pharmacy Resource Specialist
Department: Pharmacy Financial Services
Division: Pharmacy
Reports to: Coordinator, Pharmacy Reimbursement

The Pharmacy Resource Specialist manages all processes related to Pharmacy Patient Assistance Programs (PAP) for over 50 drugs. Assists indigent and underinsured patients with the enrollment process and submits required documentation to various vendor sponsored drug replacement programs. Effectively manages and facilitates timely resolution of insurance denial referrals, tracks and reconciles incoming drug shipments, and ensures patient account balances are adjusted accordingly. Serves as the primary contact for internal departments, patients, and external vendors for all aspects of the PAP process.
1. Analyzes patient data to identify potential candidates for enrollment into Pharmacy Patient Assistance Programs
a. Obtains and verifies information regarding patients enrolled / or attempting to enroll in vendor sponsored drug replacement programs
b. Pre-screens patients by evaluating documentation (including Patient Financial Assistance Applications, income documentation, proof of residency and citizenship, etc.) to confirm potential candidates meet the qualifications set forth by vendor sponsored Patient Assistance Programs c. Submits required enrollment documentation to PAP for review
d. Maintains accurate patient records/files

2. Oversees and executes replacement drug orders and tracks shipments
a. Monitors pharmacy dispense reports and discerns qualified patients based on individual program criteria
b. Compares medication administration records to physician orders to obtain correct dosing information
c. Verifies third party eligibility using tools provided (TMHP, MyMedicare, etc.)
d. Initiates replacement drug orders accurately and timely in accordance with the criteria set forth by the PAP and validates the order was received by Pharma
e. Monitors submitted drug orders and verifies shipments are received by MD Anderson in a timely manner
f. Reconciles replacement drug shipments received to orders placed
g. Maintains drug replacement inventory records and updates records upon receipt
h. Facilitates resolution of outstanding drug replacement issues timely

3. Understands hospital billing processes and Accounts Receivable management
a. Analyzes patient accounts to ensure pharmacy charges appear on the correct account in the hospital billing system
b. Demonstrates a thorough understanding of patient accounts by analyzing payments, adjustments, or denials to ensure transactions are posted prior to requesting replacement drug or issuing drug replacement adjustments
c. Initiates adjustments upon receipt of replacement drug to resolve patient balances according to policies and procedures set forth by Pharmacy Financial Services

4. Coordinates and initiates appeals process
a. Retrieves appropriate documentation for Medicare appeals
b. Prepares Medicare appeal packet and submits to fiduciary intermediary
c. Performs timely follow up on appeal status
d. Partners with various business centers, Denials Management, and Clinical Revenue and Reimbursement on appeal related issues

5. Provides oversight of Pharmacy Patient Assistance Programs and Audits
a. Creates and maintains Standard Operating Procedures (SOP) for each PAP based on the criteria set forth by the program and internal department procedures
b. Stays abreast of changes to institutional, departmental and program policies and procedures and updates SOP's accordingly
c. Provides team with updates when program requirements change at monthly team meetings
d. Prepare for audits initiated by Pharma and/or internal audit by retrieving the requested documentation and preparing patient folders
e. Evaluates patient files, identifies any potential deficiencies prior to the audit, and communicates findings to management

6. Ensures documentation and communication are provided in a timely manner
a. Documents clear, concise and complete notes in appropriate system for each case worked
b. Notifies management timely on issues related to any and all job duties
c. Uses excellent written and/or oral communication and listening skills to establish and maintain effective working relationships with internal and external customers to include: pharmacy staff, physicians, nurses, social workers, patient account staff, insurance companies, reimbursement assistance program personnel and others, as necessary, to optimize patient assistance.

Job Description-Requirements EDUCATION

Required: Bachelors of Business Administration or related degree.


Required: Three years of pharmacy reimbursement, case management, managed care or insurance industry experience. May substitute required education degree with additional years of equivalent experience on a one to one basis.

Job Requirements

Education, training, experience:
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