Pharmacy Lead - Authorization Infusion Services

Baystate Health•Springfield, MA

About The Position

The Pharmacy Lead for the Regional Infusion program oversees the non-clinical pharmacy operations and providers leadership to the staff to ensure a high-quality patient and referring provider experience. The Pharmacy Lead works closely with members of the Regional Infusion program to set and meet departmental and organization goals. This role is responsible for workflow optimization, communication, planning and implementing changes and new initiatives across locations to ensure consistency and standardization of practices. The Pharmacy Lead works with all providers and their staff to coordinate care for patients who need OP infusion/injection services in any of the Baystate Health locations. Serving as the subject matter expert for insurance prior authorizations, the Pharmacy Lead provides education and consultation services to ensure there are no delays in patient care. The Pharmacy Lead oversees the onboarding and orientation of new staff members and ensures ongoing training and competency. The Lead is responsible for establishing and maintaining consistency between multiple locations. This role drives the development and implementation of policies, procedures and SOPs. This role takes the lead to collaborate with and educate providers and their staff on all aspects of the Regional Infusion Program. In partnership with the Pharmacy Specialist for Infusions, the Pharmacy Lead makes presentations to prescribing offices to promote, train and encourage safe and efficient practices. Working closely with the Pharmacy Business Manager, the Pharmacy Lead designs, implements, coordinates and maintains a fully functional program to ensure patients are treated safety. Operating as a financial steward for the Regional Infusion program, the Pharmacy Lead stays involved and up to date in all financial aspects related to the operations of the program.

Requirements

7+ years pharmacy specific insurance authorization experience
5+ years of experience using CIS
Experience working in pharmacy environment
Experience working with high cost medications
2+ years working insurance appeals
Expert level understanding of insurance prior authorization policies and procedures for specialty and non-specialty medications
Proficiency in Microsoft Word, Excel ,Centricity Business, SMS, CIS and other applicable software applications.
Solid verbal and written communication skills.
Demonstrates a high degree of self motivation and self direction.
Associate of Arts, GED or HiSET (Required)

Nice To Haves

10 years pharmacy specific insurance authorization experience

Responsibilities

Develop and lead efforts for reporting, monitoring, and performance to specific location operating metrics, including growth plans where applicable. Tracks and reports on volumes across Regional Infusion program (all sites) Conducts ad hoc reporting as requested by management and clinical staff.
Obtain prior authorizations and referrals from third party payors for all pharmacy and related services and/or high dollar drugs that are administered to the patients, to ensure proper payment for services provided. Require all staff to adhere to program policies for documentation, communication and various insurance authorization requirements.
Maintain relevant knowledge of managed care utilization management, billing and reimbursement practices. Prevent denials by identifying and documenting payor requirements for utilization management (referrals and authorizations), by utilizing a variety of methods including websites, contracts, policy manuals, bulletins.
Identify and implement cost savings initiative for Baystate and patients receiving treatment. Assist in maintaining expenses within budget limits
Coordinate documentation necessary for insurance denials, appeals related to referral and authorization as well as other appeals as necessary for services. Collaborate across multiple departments to resolve denial/write-off issues
Participate in financial analysis, including KPI creation and management, with a goal to drive actionable results.
Maintain systems with appropriate information for patients.
Assist leadership to set and accomplish strategic initiatives, goals and milestones for overall growth and expansion
Implement and enforce system standards, policies, and procedures
Lead on-boarding and education for new prescribing providers
Participate in business development activities to support development of functional, efficient, and patient-oriented programs
Serve as subject matter expert for education and coaching for all staff (inside and outside Baystate)
Promote, educate and coach on best practices throughout infusion program, including providers, nursing, MOB staff, and pharmacy personnel.
Establish work schedules, task assignments, and resource allocation, space and equipment to ensure effective and efficient patient care and promote conformance with service commitments.
Complete operations by developing schedules, assigning, and monitoring work, gathering resources, implementing productivity standards, resolving operations problems, maintaining reference manuals, and implementing new procedures.
Identify trends or changes that may affect staffing resources, and assists in developing strategies to address these changes in demand