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Facility: Broadway Clinic
Location: Fargo, ND
Address: 737 Broadway N, Fargo, ND 58102, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
The Patient Access Specialist reviews and validates insurance eligibility, prior authorization and/or referral of medication, procedures, etc.; determines if insurance meets prior authorization criteria.
In this role, you will be primarily responsible for coordinating prior authorization and copay assistance for Specialty Pharmacy patients. Individual will also help facilitating prescription release from Sanford Clinics to the Specialty Pharmacy. Duties will include direct contact with prescribers, patients, 3rd party payors, and outside pharmacies to promote medication services at Sanford. The successful candidate will also work directly with clinic staff, pharmacists and prescriber teams through live meetings and other written / verbal communication to provide and receive ongoing feedback related to Specialty Pharmacy workflows, benefits investigation and prior authorization. The individual in this position will also document appropriately in the electronic medical record (EMR). Day to day work in this area of pharmacy will be in collaboration with our team of pharmacists and pharmacy technicians. Collects necessary documentation and communicates with third party payers, healthcare professionals and customers to prioritize requests. Verifies patient registration and confirms benefit coverage, including deductibles and out-of-pocket expenses; researches and verifies covered benefits for ordered tests, procedures, and other services.
Responsible for assuring that prior authorization for medical services, including testing, procedures, surgery, Durable Medical Equipment (DME), and medications is completed and confirmed. Obtains diagnosis(es)/CPT code(s) from medical chart and/or provider office. Contacts third party payer to determine appropriate prior authorization process. Works closely with provider offices to obtain and clarify documentation to demonstrate medical necessity. If medical necessity criteria are not met, follows up with provider offices with guidance for Advanced Beneficiary Notices (ABN) or waivers that releases the financial burden of scheduled services from the facility to the patient. Reviews professional services denials; works with clinics and third party payers on appeal process.
Assures all required referrals are in place; may work on outgoing referrals for care outside Sanford Health. May have minimal telephonic patient interaction concerning provider referrals. May notify appropriate insurance companies when patients have checked in for inpatient services and procedures requiring observation periods. Documents work in case management module; provides direction to utilization management, case management, and nursing regarding what action needs to be taken. Collaborates with case management, social work, utilization management, and other cross-functional teams across the enterprise. Assists with the design and management of data including the preparation of reports and presentations.
Sanford Specialty Pharmacy supports patients on high dollar/specialty medications (ie Multiple Sclerosis, Cystic Fibrosis, Hepatitis C, Oncology, etc.). A Patient Access Specialist in Specialty Pharmacy works closely with Pharmacists, Pharmacy Technicians, Patients and Clinic staff to efficiently coordinate Benefits Investigation for specialty medications including completing Prior Authorizations and obtaining Copay Assistance options for patients.
Ideal candidate has a background in Pharmacy Billing and/or Prior Authorization process. Background as a Pharmacy technician is preferred but not required.
Sanford Specialty Pharmacy is open Monday through Friday 8am to 5pm. The pharmacy is closed all major holidays.
High School graduation or general education diploma (GED) is required; post-secondary education helpful.
Minimum of two years of experience in a hospital or clinic setting required. Understanding of medical terminology, insurance background, office equipment and computers is required.
Sanford is an EEO/AA Employer M/F/Disability/Vet.
If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to email@example.com .
Job Function: Revenue Cycle
Req Number: R-33619