Specialty Pharm Rep- Fulfillment- KOP

Jefferson Health; Raleigh (NC); On-site; USD 42,000 - 62,000; Full time

Job summary

Thomas Jefferson University Hospitals, Inc. is seeking a Specialty Pharmacy Representative I to support refill queues and assist patients, physicians, and pharmacists with adjudication, benefit investigations, and financial assistance programs.

This role ensures accurate patient data entry and helps with dispensing under a pharmacist's direction. The position involves coordinating high-value medication deliveries, addressing insurance copay challenges, and liaising with care teams to optimize

Qualifications

• High School Diploma or GED equivalent preferred.
• AS/BS degree preferred; CPhT certification preferred.

Responsibilities

• Adjudicate and review claims responses for reimbursement and profitability.
• Analyze claims messages to determine next steps for order escalation (Prior Authorization, Benefits Investigation, Step Therapy, Non-Formulary, Financial Assistance).
• Schedule delivery of high dollar/specialty medications and maintenance meds to maintain adherence.
• Assess patient need for clinical intervention based on refill questions or related information.
• Identify barriers to care and escalate to clinical support when appropriate.
• Review patient chart for accuracy and completeness.
• Explain insurance coverage to patients regarding copays and resources.
• Screen patients for financial assistance and apply when applicable.
• Print paperwork and fill prescriptions under supervision of a clinical pharmacist.

Skills

Claims adjudication

Benefits investigation

Patient communication

Pharmacy terminology

Financial assistance

Delivery coordination

Education

AS/BS degree preferred

Certified Pharmacy Technician (CPhT) preferred

Tools

Patient assessment software

Job description

Job Details

PRIMARY RESPONSIBILITIES

The Specialty Pharmacy Representative I drives our refill queues and assists patients, physicians and pharmacists in the completion of: claim adjudication/review, benefit investigations, financial assistance applications, refill/adherence activities, and other programs that drive optimal outcomes for Jefferson Specialty Pharmacy patients. Responsibilities include entering the patient information; name, date of birth, insurance information, allergies and medication history into our therapy-specific patient assessment software. Assist with the filling and distribution of prescriptions, under the direction of a patient care pharmacist, in accordance with the law. Job Description Location: 3500 Horizon Dr, King of Prussia, PA 19406

ESSENTIAL FUNCTIONS

• Adjudicate and review claims responses for reimbursement and profitability
• Analyze claims messages to determine next steps for order escalation as needed: Prior Authorization, Benefits Investigation, Step Therapy, Non-Formulary, Financial Assistance, etc
• Schedule delivery of high dollar/specialty medications as well as other maintenance medications to maintain patient adherence and compliance to prescribed therapy according to departmental policy and guidelines
• Assess patient need for clinical intervention based on how they answer the refill questions or any information they may provide unrelated to the refill assessment
• Identify any barriers to care, non-compliance, changes in therapy/dosing and escalate to the clinical support team when appropriate
• Review patient chart to ensure all information is accurate and up to date
• Explain insurance coverage to patients as it relates to their copay responsibility and financial resources available to them
• Screen patients for financial assistance and apply on their behalf where applicable
• Print paperwork and fill prescriptions under the supervision of a clinical pharmacist
• Track and monitor deliveries to ensure medication arrives to patient undamaged; intervene where necessary to reship delivery
• Contributes to departmental Quality Assurance/Quality Improvement activities. Expected participation no less than 2% of time – increased participation based on need/project.
• Interacts with co-workers, visitors, and other staff consistent with the iSCORE values of Jefferson

OTHER FUNCTIONS AND COMPETENCIES

• Act as a liaison between the patient and their insurance company, foundations, and manufacturers
• Knowledge of commercial, Medicaid, and Medicare billing and understanding program requirements for all types of coverage
• Demonstrated ability to listen skillfully, collect relevant information, and build relationship and trust with patients and providers
• Respond to customers in a compassionate manner
• Multi-task between several issues at one time
• Problem solve to serve patients and ensure their medications are processed, ordered and delivered in a timely manner.
• Independently resolves complex customer conflicts including but not limited to: damaged/lost products, order placement, and outstanding balances and invoices
• Proactively document and recognize cause and effect trends
• Knowledge and understanding of the following: medical terminology and medical terminology used by insurance, the Health Insurance Portability and Accountability Act, and of principles and practices associated with the rights and responsibilities of patients and caregivers.
• Knowledge of and ability to utilize software, technologies and applications to interact with customers via a telephone, web or other electronic means.
• Knowledge of the major responsibilities, accountabilities, and overall organization of the customer support function or department, ability to properly support customer inquiries and bring problems to a timely resolution.
• Knowledge of and ability to utilize practices, tools, and techniques for communicating with a customer

EDUCATIONAL/TRAINING REQUIREMENTS

High School Diploma or GED equivalent preferred

CERTIFICATES, LICENSES, AND REGISTRATION: AS/BS degree preferred; Certified Pharmacy Technician (CPhT) preferred