Pharmacy Access Representative III - DME

001 University of Rochester; United States; On-site; USD 62,954,000 - 84,988,000; Full time

Job summary

University of Rochester is seeking a Pharmacy Access Representative III to manage medical equipment, verify insurance, and coordinate delivery of durable medical equipment. The role focuses on removing barriers to patient access and ensuring timely and accurate claims submission in a hospital setting.

The PAR III supports physician offices, case managers, and patients, and maintains adherence to confidentiality policies while delivering excellent customer service and coordination across

Qualifications

• At least 18 years of age.
• Associate’s degree in Medical, Secretarial, or related field and 4 years of relevant experience required.
• Or equivalent combination of education and experience.
• Capable of working independently with minimum supervision.
• Strong communication, problem-solving, and customer relations are required.
• Ability to multi-task, manage details, work under pressure, and maintain professionalism.

Responsibilities

• Manage medical equipment and supplies, and remove barriers to patient equipment access.
• Verify insurance coverage and determine patient costs; prepare documentation for payment.
• Coordinate with prescriber offices to obtain information for claims including prior authorization.
• Serve as liaison among patients, referral sources, insurance, and staff for coordinated care.
• Coordinate delivery and resupply of equipment with HME staff and couriers.
• Triages patient calls and monitors adherence to treatment; provide excellent customer service.

Skills

Phone etiquette

Customer service

Communication skills

Problem solving

Multi-tasking

Education

Associate’s degree in Medical/Secretarial or related field

4 years of relevant experience

Equivalent combination of education and experience

Tools

ASHP training

PTCB certification

Job description

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): 155 Bellwood Dr, Rochester, New York, United States of America, 14606

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 URCB 206 H

Compensation Range: $21.97 - $29.66

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:

• The Pharmacy Access Representative III (PAR) is responsible for the overall management of medical equipment and supplies, coverage determination, and removal of barriers that prevent patients from receiving their equipment.
• Duties will include insurance coverage verification and determination, patient cost estimation, assembly of documentation necessary to ensure payment for equipment in compliance with payer standards.
• The PAR will communicate with the prescriber’s office to acquire necessary information to submit claims to the patient’s insurance for approval including prior authorization and helping educate patients with financial need and arrange timely delivery of the equipment.
• The PAR will link communication between the patient, referral source, insurance, and staff to ensure coordinated care.
• The PAR will be assigned to a general service area such as hospital discharges and respiratory care.
• Daily tasks are completed independently and prioritized based on the patient and pharmacist needs.
• Duties of this position require proper judgement, sensitivity, and strict adherence to Strong Memorial Hospital policy on confidentiality and the protection of Private Health Information.
• The PAR interacts with multiple individuals within the institution including, but not limited to, hospital and clinical employees at various levels including pharmacists, pharmacy technicians, and medical/clinical staff.
• External interactions include third party payors, governmental peer review organizations, and referring physicians.
• To be successful, this individual must have excellent phone etiquette and be open to feedback to create strong collaborative work relationships.

Essential Functions:

• Home Medical Equipment Coordination Coordinates Home Medical Equipment (HME) and supplies referrals and delivery coordination with home medical equipment staff to ensure timely delivery.
• Troubleshoots insurance issues with referral sources, , physicians and other clinical and internal staff to prevent interruptions in receiving equipment or therapy.
• Acts as liaison between home care coordinators, discharge coordinators DME staff and providers to obtain accurate information related to coverage requirements for medical equipment.
• Coordinate delivery utilizing various options such as UR DME technicians, UR Couriers and other commercial services.
• Coordinate resupply for consumable items such as CPAP/BIPAP Staff HME storefront locations; assist patients with selection and purchase of equipment, as well as educates them on the different options that are covered with their insurance.
• If insurance does not cover the equipment needed, they support the patient in finding alternative programs to cover the cost of the equipment.
• Follow-up with patients to ensure safe and effective equipment use.
• Documents problems with the equipment (i.e. delivery issues, broken equipment, monitors CPAP and other respiratory equipment use and adherence, difficulty with use, etc.) and triages issues to management and clinical staff as appropriate.
• Coordinates medical equipment ordering with inventory manager.
• Tracks changes in ordering trends and coordinate with inventory manager if changes in stock on hand is needed.
• Makes scheduled calls to patient to determine resupply needs and set up deliveries.
• Facilitates adherence to treatment by monitoring compliance and communicating with patients and clinical staff.
• Provides excellent customer service by Triaging patient calls to appropriate party.
• Answer incoming calls in a timely manner.
• Monitors and reconciles patient self-pay accounts once a month.

Financial Management:

Maintains expertise on all insurance coverage and requirements for home medical equipment.

Retrieve and evaluate home medical equipment referrals to verify insurance coverage and contract for equipment.

Obtain benefit information from third party payers to advise patients on their expected out of pocket costs taking into account deductibles, coinsurance, copayments or total charges if services are not covered.

Determine if equipment being ordered meets payer requirements for coverage.

Retrieve and assemble necessary information for insurance coverage qualifications as needed.

Communicates out of pocket costs to patients, care givers or coordinators.

Identifies coverage gaps and utilizes resources through social workers, charity care or other assistance programs.

Serves as a subject matter expert available to patients, providers, social work, and others regarding alternative payment methods such as Chairty care.

Creates and confirms sales orders for equipment provided and work collaboratively with respective service lines that are needed to assemble information necessary for billing.

Analyzes patients that are high-cost equipment for potential options and identifies the best option(s) for the patient given their overall circumstances (insurance, disease state, income, etc.).

Coordinates with the patient and/or family to obtain necessary information including income information and other personal details, as well as to present options to the patient/family when there are multiple options.

Collaborates with social services and case management on patient assistance.

Compliance and Quality:

Remains professional, courteous and diligent in all interactions with staff and patients/families.

Obtains high patient and provider satisfaction results.

Reports errors through hospital error reporting system (RL solutions) and contribute to quality improvement initiatives.

Assists with payer audits and ensure timely completion of required patient documentation.

Coordinate required information for denied claims.

Participate in payer audits and collect, summarize and send requested information.

Assists with training of new team members in designated clinical area.

Performs other related duties as required, including work relating to the Intake Pharmacy Access Representative.

Prior Authorization Management:

Maintains expertise of the current policies of the most common payors for the relevant equipment that require prior authorization (PA), and will be responsible for working with the prior authorization coordinators, office staff nurses and other patient care staff to assure that all required elements of the policy are applicable in advance of requesting PA.

Submit and monitor prior authorization requests timely.

Initiates, documents, and tracks all prior authorization on behalf of the areas to improve patient experience, ensure compliance, and prevent interruptions or delays in treatment.

Minimum Education & Experience:

At least 18 years of age at the time of application.

Associate’s degrees in a Medical, Secretarial, or related field and 4 years of relevant experience required.

Or equivalent combination of education and experience.

Knowledge, Skills & Abilities:

• Capable of working independently with minimum supervision required.
• Strong communication skills, problem-solving abilities, and professional presentation required.
• Demonstrated customer relations skills required.
• Ability to multi-task, manage many details with accuracy, work under pressure, and maintain a professional attitude required.

Licenses and Certifications:

• Completed ASHP-accredited training program or equivalent experience as a pharmacy technician preferred.
• Certification from a nationally accredited pharmacy technician certification program (Currently PTCB) and maintain ongoing education requirements preferred.

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better.

In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics).

This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

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Located in western New York, Rochester is our namesake and our home.

One of the world’s leading research universities, Rochester has a long tradition of breaking boundaries—always pushing and questioning, learning and unlearning. We transform ideas into enterprises that create value and make the world ever better.

If you’re looking for a career in higher education or health care, the University of Rochester may offer the perfect opportunity for your background and goals.

At the University of Rochester, we are committed to fostering, cultivating, and preserving an inclusive and welcoming culture and are united by a strong commitment to be ever better—Meliora. It is an ideal that informs our shared mission to ensure all members of our community feel safe, respected, included, and valued.