Sanford Health Patient Access Specialist - Specialty Pharmacy in Fargo, North Dakota
Job Title: Patient Access Specialist | Specialty Pharmacy | Fargo
Department : Phase 2 Positions
Job Schedule: Full Time
Hours Per Shift: 8 hr
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.
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. Requires knowledge of and proficiency in the use of compute
Utilizes database design tools and techniques.;Detects and summarizes patterns in data and findings by producing simple reports.;Delivers written and oral communication, responds to questions and concerns, and produce specific outcomes and impact.;Applies existing medical data in the decision-making processes.;Addresses documentation issues to support claim processing that is in-line with regulations and rules.;Interprets all significant components of health insurance.;Assists patients in accessing specialized providers through the use of referrals or pre-approvals.;Works with providers to secure necessary medical records and authorize routine treatments.;Verifies all insurance information is up to date and correct; maintains patient data in an electronic registration system and on patientâ€™s chart.;
This position will focus on obtaining Patient Assistance for Sanford Specialty Pharmacy patients. Position will work with manufacturer copay assistance programs and national foundations to help offset the costs of medications once prior authorization obtained. Day to day duties will include contacting patients to obtain financial information, applying patients to foundations, working with the pharmacy team to ensure patients are able to start medications, and various other duties to support the pharmacy.
High School graduation or 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.
About Sanford Health:
At Sanford Health, we are dedicated to the work of health and healing.
Every day, we show that commitment by delivering the highest quality of care to the communities we serve.
We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care, leading-edge technologies and world-class facilities.
In addition to strong clinical care, we are also committed to research, education and community growth.
We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases.
We continuously seek new ways to achieve our vision of improving the human condition here in your community, across the region and around the world.
The entire team at Sanford Health recognizes the value of healthy families and communities.
We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.
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
Job Schedule: Full Time
Req Number: WD07415