Pharmacy Benefits Specialist - Ambulatory

Henry Ford Health; Troy (MI); On-site; USD 55,000 - 75,000; Full time

Job summary

Henry Ford Health in Detroit is seeking a Pharmacy Benefits Specialist for ambulatory care to manage drug claim adjudication, prior authorizations, and inquiries from members, physicians, and pharmacies. You will be a subject matter expert in resolving benefit coverage issues and coordinating authorization and exception processes.

The role involves benefits investigation, patient financial assistance, and effective communication of authorization outcomes to patients and providers, ensuring

Qualifications

• Requires a High school diploma or GED; associates degree preferred.
• Michigan Pharmacy Technician license is required.
• Minimum two years of pharmacy technician experience; specialty pharmacy preferred.

Responsibilities

• Handle benefits investigation and prior authorization for patients.
• Research financial assistance to ensure medication access.
• Manage inquiries from providers, clinics, and patients.
• Interpret treatment plans and medical notes for care facilitation.
• Communicate authorization outcomes to patients and providers.
• Order entry steps to ensure timely dispensing and verification.
• Coordinate with nursing, social workers and physician staff on barriers.
• Perform pharmacy technician duties including data entry and dispensing when needed.
• Triaging clinical questions to pharmacists, nurses or providers.
• Document medication history in applicable systems.
• Assist with orientation and training of new hires.

Skills

Benefits investigation

Prior authorization

Multidisciplinary collaboration

Time management

Customer service

Medical terminology

Education

High school diploma or GED

State of Michigan Pharmacy Technician License

Associates degree preferred

Tools

Epic

Cerner

McKesson Enterprise

QS1

RX30

Asembia

Therigy

Dromos PTM

Job description

Pharmacy Benefits Specialist - Ambulatory

• Full-time

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford's care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation's most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus.

GENERAL SUMMARY:

The Pharmacy Benefits Specialist is responsible for handling drug claim adjudication issues, prescription prior authorization, and pharmacy benefit inquiries from members/patients, physicians, pharmacies, and other internal and external individuals. Is a subject matter expert in the resolution of pharmacy benefit coverage issues and coordinating prior authorization and exception processes.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Performs benefits investigation, prescription prior authorization, and researches financial assistance needed to ensure patients have access to medications needed.
• Acts as a central resource to manage and monitor all medication related inquiries from providers/clinics.
• Interprets patient treatment plans and medical notes for purposes of facilitating patient care.
• Communicates in timely manner to patients and providers regarding authorization outcome.
• Evaluates any pharmacy related inquiries (i.e., financial barriers, therapy management related outcomes, non-adherence to therapy) and communicates with nursing, providers, social workers and physician staff any additional requirements or potential barriers to the treatment plan.
• Performs all necessary steps during order entry to ensure order gets to final verification. Ensures the process is completed quickly, accurately, and in accordance with patient's needs while maintaining the highest customer service/quality of care.
• Performs online ordering of prescriptions submitted to pharmacies. May perform pharmacy technician duties (i.e., data entry, product dispensing, selling prescriptions on the POS and delivering prescriptions).
• Communicates directly with enrolled patients to ensure that they are supported throughout their therapy regimen and achieve their intended outcome.
  • This includes: Conducts outbound phone calls for patient support, adherence checks, and refill reminders.
  • Accepts inbound calls from patients and addressing patient needs.
  • Appropriately triages clinical questions to the appropriate clinician (pharmacist, nurse, or provider).
  • Obtains and documents medication history in appropriate software systems.
• Acts as a resource to assist with orientation and training of new hires.
• Creates and maintains patient/member information in applicable systems.
• Performs additional related duties as assigned.

EDUCATION/EXPERIENCE REQUIRED:

• Requires a High school diploma or G.E.D. Associates degree preferred. Requires State of Michigan Pharmacy Technician License.
• Requires a minimum of two years of previous pharmacy technician experience.
• Previous experience as a specialty pharmacy technician preferred. Knowledge in the specialty disease states (Oncology, Autoimmune Disease, Neurology, Hepatology, other miscellaneous Specialty Diseases) preferred.
• Experience working with multidisciplinary team. Knowledge of benefits investigation, prior authorization support, and patient financial assistance work preferred.
• Requires a strong understanding and knowledge of medical/clinical and pharmacy terminology. Proficiency in standard workplace software (MS office) required.
• EMR systems (Epic or Cerner), dispensing systems (McKesson Enterprise, QS1, or RX30) and specialty pharmacy patient management programs (Asembia-1, Therigy, or Dromos PTM) experience is preferred.
• Requires organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and job duties/responsibilities.
• Must be reliable and willing to assume additional responsibilities.