Prior Authorization Team Coordinator/Certified Pharmacy Technician- Outpatient Pharmacy in Cookeville, Tennessee at Cookeville Regional Medical Center

The Ambulatory Medication Prior Authorization Coordinator (AMPAC) is a position residing in the Outpatient Pharmacy Department. Under the guidance of the Outpatient/Specialty Pharmacy Manger– Specialty Pharmacy, the AMPAC is responsible for completing necessary functions to ensure optimal reimbursement for high cost, take home medications for patients receiving care with the health system. The AMPAC is primarily responsible for conducting and completing necessary third party (insurance) prior authorization requests and associated services related to high cost medications, maximizing efficiency for patients and clinic staff. Other areas of responsibility include pre-screening patients for viable payment sources, managing reimbursement issues associated with high cost take-home medications, identifying opportunities for improving reimbursement from payers, compiling reports for contract optimization, completing the necessary paperwork for prior authorizations, and conducting retrospective utilization reviews on cases payment denials or insufficient reimbursement. This position will help to assure seamless communication between clinics and a patient’s preferred pharmacy of choice.

A wide variety of internal and external relationships are inherent to the success of this position. The incumbent interacts with hospital employees on multiple levels, including pharmacists, medical/clinical staff, fiscal personnel, department managers, access services staff, coding staff and billing assistants. External contacts include third party payers, prescription benefit management companies, governmental peer review organizations, and referring physicians. Strong communication skills, problem-solving abilities, and a professional presentation are imperative along with an ability to be innovative and creative. To be effective, this position must be able to establish collaborative working relationships.

The incumbent acts independently with the help of general policies and procedures and practice guidelines to facilitate the processes with support from the pharmacy, access services, and fiscal leadership. This position has independent responsibility for organizing and planning work in order to accomplish daily responsibilities as well as broad goals and objectives.

A substantial portion of the normal duties of the incumbent requires proper judgment, sensitivity and strict adherence to Hospital and Clinic policy on confidentiality.

MAJOR RESPONSIBILITIES
The incumbent performs the following job responsibilities:

A. Review and evaluate outpatient take-home medications to assure the appropriateness and medical necessity of medication use based on established criteria. Obtain prior authorization from intermediaries and payers, including managed care companies, insurance companies, and review organizations. Ensure completion of activities that maximize revenue capture for high-cost medications.
1. Conduct prospective prior authorization services to expedite clinic workflow and enhance patient care by preventing therapy interruptions due to insurance paperwork issues.
a. Further develop collaborative practice with specialty providers and clinics caring for patients with high-cost, high-risk “specialty” disease states.
b. Complete all take home medication-related prior authorization paperwork on behalf of the physician and clinic staff with minimal interruption of clinic operations.
1. Utilize EMR and chart review to obtain pertinent medical information for prior authorization processing.
2. Communicate directly with patients and insurance companies to obtain information inaccessible in EMR.
3. Conduct insurance reviews for appropriateness of therapy initiation and/or continuation with recommendations for additional labs as necessary.
4. Interact with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation to ensure accurate indications in the patient’s medical record before completion of third party prior authorizations. This may include contacting referring physicians for information.
5. Submit prior authorization requests to insurance companies and follow-up as necessary to completion.
c. Communicate directly with clinic staff regarding patient therapy interruptions (intentional and unintentional) to allow for lab value aberrations and additional monitoring when necessary.
d. Collaborate with physicians, pharmacists, and clinic staff on an alternative delivery of care setting when appropriate (i.e. take home subcutaneous versus clinic administered).
2. Improve patient service experience and retail pharmacy revenue through provision of prior authorization services in clinics.
a. Review high cost medications prescribed for outpatients across the system, conduct patient insurance and financial review, and facilitate adherence to medications by ensuring that patients receive prescribed medications in a timely manner.
b. Maximize revenue capture for high cost take-home medications by completing third party (external) medication authorizations on behalf of clinics for select high cost medications.
1. Maximize clinic understanding of services provided by hospital retail pharmacies.
2. Work collaboratively with clinic staff to educate and inform patients about hospital retail pharmacy services.
c. Provide exemplary customer service to patients being served at hospital clinics.
d. Respond to complex questions from third party payers and clinic staff regarding medication-related issues and reimbursement.
e. Utilize resources such as EMR, email, and telephone to communicate pertinent patient information to clinic staff.
f. Prescreen payment sources to identify payers who do not recognize hospital as a preferred specialty pharmacy provider. Collaborate with clinic staff and providers to streamline patient referral to hospital pharmacies or other appropriate care provider(s).
g. Assist the Medication Prior Authorization Coordinator in reviewing and resolving pockets of clinic-administered but ambulatory appropriate medications.
3. Observe and understand prescribing trends within hospital clinics to identify areas for improved specialty pharmacy contracting.
a. Work with clinical pharmacists and prescribing physicians to understand prescribing practices within medication classes for high cost take home medications.
b. Develop reports for the ambulatory management team that illustrate past and current prescribing trends, as well as capture rate of high cost take home medications within hospital retail pharmacies.
c. Generate educational materials for clinic staff for medications that require prior authorizations, as well as insurance limitations and exceptions.
d. Maintain data including prior authorization expiration dates to ensure prospective clinical review.
4. Develop an effective working relationship with external entities.
5. Refer appropriate patients to the Medication Assistance Program (MAP). Identify self-pay patients eligible for enrollment into the MAP and coordinate enrollment with the MAP staff. Problem solve with Community Care Coordinator for patients ineligible for MAP programs.

Performance Measures
• Professional performance displayed by professional behavior, a positive and supportive attitude with customers, co-workers, and outside agencies.
• Maintains confidentiality of all patient-related information.
• Demonstrates efficiency and effectiveness in chart review functions.
• Customers (internal and external) are polled for feedback.
• High-cost medication referral rates to hospital ambulatory pharmacies.

B. Under the guidance of the pharmacy management team, develop marketing materials and communication strategies with the goal of increasing patient recruitment and the prescription capture rate of high cost take-home medications within hospital retail pharmacies.
1. Maximize patient referral to hospital ambulatory pharmacies through increased awareness of services and patient recruitment.
2. Communicate effectively with clinic staff to promote the prior authorization services offered by the Pharmacy Department to patients with high-cost take home medications.
3. Develop marketing materials for patients and clinic staff that provide information on the services offered through this position, as well as prescription options through hospital retail pharmacies and mail order pharmacy options.
4. Collaborate with clinic managers and staff to market pharmacy services to patients served.
C. Assist with the development and implementation of policies and procedures to ensure reimbursement of high cost medications.
1. Utilize computer applications to efficiently/effectively enter and track prior authorization information, retrospective reviews and denial follow-up data.
2. Ensure compliance with regulatory and accreditation agencies (HIPAA, TJC, HCFA, etc).
3. Provide denial/appeal data to physicians on a consistent basis.

Performance Measures
• Maintains an organized and efficient work environment.
• Maintains ability to utilize hospital computer system and other systems necessary to perform job.
• Manager evaluation of employee performance based on Core Organization Competencies.
• Policies/procedures checked for updates and accuracy

Education: High School Diploma or GED required. TN Pharmacy Technician license required. PTCB Certified required.

Minimum: Equivalent combination of education and experience will be considered.
Preferred: 3 to 5 years of pharmacy technician experience in a retail pharmacy