Specialty Pharmacy Business Coordinator

2 weeks ago

South River, United States Hackensack Meridian Health Full time
Description:

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Specialty Pharmacy Business Coordinator oversees the specialty pharmacy business according to departmental standards, internal and external reporting requirements, accreditation standards, and pharmacy laws and regulations. This includes managing revenue cycle operations and maintaining comprehensive knowledge of payer relations, claims adjudication, contractual claims processing, and general reimbursement procedures. The Specialty Pharmacy Business Coordinator engages with internal and external stakeholders to secure access to and inclusion in specialty pharmacy provider networks, accreditation, and overall business management. Furthermore, the Specialty Pharmacy Business coordinator ensures network ambulatory pharmacy claim remittances from third-party payers are received, reconciled, and posted accurately and promptly to the appropriate pharmacy account. They work to minimize aged receivable days, address underpaid claims, and resolve missing payments, collaborating closely with contracted PSAOs, HMH Reconciliation vendors, payers, and site pharmacy leaders. This role requires an understanding of underlying payer contracts and involves maintaining payer agreements, assisting with new vendor contracting, and re-credentialing as needed with PBMs, Medicare, Medicaid, and other payers/entities.

Responsibilties:

A day in the life of a Specialty Pharmacy Business Coordinator at Hackensack Meridian Health includes:

  • Oversees pharmacy billing and accounts receivable management systems.
  • Ensures that specialty pharmacy financial reconciliation of all third-party claims is accurate, posted, and communicated to HMH Finance & Accounting.
  • Serves as primary contact for all claim reconciliation for both PBM and Medical Claims.
  • Provides financial reporting data on claims days and total dollars outstanding from third parties to the Network Director of Pharmacy Business & Finance.
  • Assists with or directs any banking issues related to deposits, refunds, and credit card processing.
  • Works closely with specialty pharmacy leadership, PSAO, and PBMs and serves as an intermediary with any HMH Contract Vendor Partners (e.g., Advis) to ensure PBM contracts are completed and assists with re-credentialing as needed.
  • Works closely with site leaders to ensure that Medicare/Medicaid agreements are up-to-date and assists with preparation for site visits.
  • Ensures Medical Billing/Medicare Billing claims are processed and posted and follows up with site leaders to complete denied or incomplete claims timely.
  • Coordinates with HMH Network Insurance department to ensure that sites receive COI and Surety Bond updates annually or as needed and ensures they are uploaded to NCPDP.
  • Schedules site annual inventories and maintains records. Provides to network finance leaders or responsible parties as needed.
  • Helps automate data processing and reporting where possible using all possible robot or AI tools available.
  • Assists sites with any patient-related pharmacy A/R issues and serves as SME for HMH Payroll Deduction, POS, and any patient-related A/R issues.
  • Researches and maintains 3rd party insurance contracts and negotiates pharmacy reimbursement rates and language with payers.
  • Ensures timely and accurate billing of all pharmacy charges and reimbursement activities.
  • Establishes strong relationships with staff members at payer/insurance organizations and manages/maintains pharmacy contracts.
  • Periodically reviews pharmacy contracts for updates or changes in contract language and seeks higher reimbursement rates.
  • Manages customer service-related phone calls or written requests for pharmacy contracting issues and ensures timely resolution.
  • Identifies new specialty pharmacy opportunities based on current restricted payer networks, limited distribution drugs, pipeline specialty pharmacy drugs, and other specialty pharmacy opportunities.
  • Works with payers and manufacturers to gain access to limited distribution drugs and payer networks, providing regular updates to the Director on network access status.
  • Interacts with payers, insurance companies, pharmaceutical manufacturers, and other stakeholders to establish and maintain relationships that will grow and sustain the business.
  • Works with the Specialty Pharmacy Director and leadership team on designated projects as requested.

Qualifications:

Education, Knowledge, Skills and Abilities Required:

  • High School diploma, general equivalency diploma (GED), and/or GED equivalent programs.
  • Minimum of three (3) years of experience in Pharmacy Claims Reconciliation.
  • Must be comfortable using multiple software programs.
  • Must be organized and possess effective time management skills.
  • Must be able to communicate clearly and effectively, both verbally and written.
  • Detail-oriented (or ability to perform duties with the highest degree of accuracy).

Education, Knowledge, Skills and Abilities Preferred:

  • Retail or Specialty Pharmacy experience, especially claims management and reconciliation.
  • Strong knowledge and experience with PBM contract completion.

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today

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