Pharmacy Reimbursement Specialist II
Evaluates reimbursement of medications provided to inpatients, clinic patients and patients receiving prescriptions through the outpatient pharmacy network. Works with multidisciplinary groups to develop proper procedures and programs to maximize reimbursement. Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals. Assists with maintaining drug and payer data files in the dispensing system. Works with dispensing staff and/or Payor Help Desk Staff to troubleshoot issues with medication claims &, when needed, editing / resubmitting claims in the OP dispensing system.
- Associate's Degree (or equivalent experience)
- 3 years Healthcare reimbursement or pharmacy finance
- Registered Pharmacy Technician Required
Additional Qualification Information:
- Tennessee Board of Pharmacy Technician Registration. PTCB/CPT National Pharmacy Technician Certification (Required).
Department Summary: To provide outstanding patient care by optimizing medication use and ensuring patient safety. Our commitment extends to our patients, customers, & community and encompasses service, teaching and research to optimize medication-related outcomes.
- Clarify and trend pharmaceutical denials and underpayments of the highest cost drugs and other drugs.
- Utilizes data from finance and pharmacy systems to determine reimbursement rates for pharmaceuticals for various patient care settings.
- Evaluates actual reimbursement compared to defined contractual reimbursement rates for specific drugs/procedures.
- Provides trending on reimbursement and information on areas for focus to maximize reimbursement.
- Maintains data in appropriate database to facilitate evaluation and presentation of data.
- Evaluates data enabling the identification of trends by multiple variables.
- Work with patient accounting, finance, contracts and pharmacy to develop strategy for improved reimbursement.
- Utilizing data collected, defines areas for focus to maximize reimbursement and presents plan to above departments.
- Maintains list of potential opportunities for reimbursement and contracting based on proactive review of data.
- Works collaboratively to develop programs and procedures to maximize reimbursement of pharmaceuticals.
- Facilitates process and system improvements to reduce the likelihood of occurrence of loss of reimbursement relating to pharmaceuticals.
- Works with pharmacy staff and finance to evaluate reimbursement of new drugs and proposes necessary procedures to maximize reimbursement.
- Document enhanced reimbursement from developed programs and trend success of programs.
- Utilizing databases maintained to provide documentation to support the effectiveness of the reimbursement program. Assists with regulatory compliance related to safe medication use with program, operational, regulatory bodies (JCAHO, ASHP, state and federal regulations, Leapfrog, etc.), and institutional policies and procedures.
- Provides written monthly update on activities and financial impact of program to enhance reimbursement.
- Assists billing manager and documents regulatory compliance related to billing of pharmaceuticals and works to correct any variances.
- Work with Patient Assistance Programs (PAP) to include identifying new opportunities, document receipt of funds and provide proper adjustment of patient accounting accounts.
- Collaborates with pharmacy, finance, contracts and patient accounting to identify ongoing opportunities to expand the PAP to reduce drug cost.
- Documents savings from the PAP and provides a monthly report trending the savings from the program.
- Provide recommendations to pharmacy administration for input into hospital contracting for enhanced reimbursement.
- Maintains proper resources and contacts to understand the contractual reimbursement of pharmaceuticals.
- Maintains documentation on any issues with contractual reimbursement including the financial impact for review by pharmacy, finance and contracting.
- Contributes to the continuing education of pharmacy on the reimbursement of pharmaceuticals and the contractual trends for reimbursement.
- As permitted by law, may receive or transfer oral prescriptions for dispensed medications under the supervision of a pharmacist.
Discover Vanderbilt University Medical Center:
Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.
Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled
VUMC Recent Accomplishments
Because we are committed to providing the best in patient care, education and research, we are proud of our recent accomplishments:
- US News & World Report: #1 Adult Hospital in Tennessee and metropolitan Nashville, named to the Best Hospitals Honor Roll of the top 20 adult hospitals, 10 nationally ranked adult specialty programs, with 3 specialties rated in the top 10 nationally, Monroe Carell Jr. Children's Hospital at Vanderbilt named as one of the Best Children's Hospital in the nation, with 10 out of 10 pediatric specialties nationally ranked.
- Healthcare's Most Wired: Among the nation's 100 "most-wired" hospitals and health systems for its efforts in innovative medical technology.
- Becker's Hospital Review: named as one of the "100 Great Hospitals in America", in the roster of 100 Hospitals and Health Systems with Great Oncology Programs and to its list of the 100 Hospitals with Great Heart Programs.
- The Leapfrog Group: One of only 10 children's hospitals in the to be named at Leapfrog Top Hospital.
- American Association for the Advancement of Science: The School of Medicine has 112 elected fellows.
- Magnet Recognition Program: Received our third consecutive Magnet designations.
- National Academy of Medicine: 22 members, elected by their peers in recognition of outstanding achievement.
- Human Rights Campaign Healthcare Equality Index: 6th year in a row that Vanderbilt University Medical Center was a Leader in LGBTQ Healthcare Equality.