Pharmacy Svcs Payor Credentialing

Responsibilities/Job Description:

Establish and maintain patient access to Fairview Pharmacy services across the system (26 Retail pharmacy sites; 11 Acute Care pharmacy sites; 22 pharmacy Infusion sites; 45 MTM sites; Specialty, and Compounding pharmacies, and 340B program credentialing, $1.8B annual revenue) by applying expertise and knowledge of contractual obligations required by PBMs and Managed Care Organizations as well as mandatory government requirements for enrollment with Medicare and Medicaid (for all 50 states) to ensure uninterrupted patient access to the Fairview System's pharmacy services.

Manage system wide timely responses to all government inquiries regarding pharmacy services program integrity. Be the subject matter expert for the Fairview system, including all pharmacy site teams, on government and commercial pharmacy program enrollment and credentialing requirements and deliverables.

This position requires advanced knowledge of complex pharmacy businesses across a large integrated healthcare delivery system. This position is accountable for the successful initial and ongoing enrollment and credentialing of Fairview Pharmacy Services with all third-party payors, local, regional, and national required to ensure reimbursement is received for pharmacy services rendered across the Fairview System ($1.8B Annual Net Revenue).

**This is a remote position**

Job Expectations:

Enrollment Management

• Advanced working knowledge of Medicare, Medicaid, and third-party insurance/ payor plans.
• Lead internal system wide customers with Medicare and Medicaid enrollment processes and refer customers to other resources as needed. Lead transplant finance team as subject matter expert for out of state Medicaid enrollment processes and apply independent judgment and discretion for decision making throughout the enrollment process.
• Lead external customers in license submission maintenance for out of state Medicaid. Monitor and maintain continued enrollments by pursuing re-enrollment prior to expiration dates to ensure continuity in ability for sites to bill for reimbursement by third party payors for pharmacy services rendered.
• Oversee the management and maintenance of extensive records for all current government enrollments for all sites across the Fairview System, and all current contracted PBMs and Managed Care Organizations. Oversee, verify, and manage all site-specific credentialing files. Organize past and current submissions for credentialing. Retrieve and securely maintain all confidential credentialing information required by third party payors related to pharmacy and other operations leadership. Maintain strong relationships and open communication with operational leadership when leaders turnover in order to maintain the integrity of pharmacy credentialing files as accurate and timely as possible with all third-party payors.
• Manages and independently responds to incoming and outgoing communication from all CMS/Medicare governmental contractors by serving as the primary point of contact for such requests, documentation, and research.
• Perform quality review of documentation to ensure established pharmacy guidelines and state and federal requirements are adhered to. Exercises independent judgment and discretion when interpreting changes in requirements and guidelines from payors as slight changes could result in significant changes to patient care/ access to services and have material financial impact for patients and Fairview Pharmacy Services. When necessary, escalate needed deviations from status to Director / leadership and provide subject matter expertise when recommending changes.
• Helps others across the Fairview System research multi-part and sensitive enrollment issues or problems. Assist Director with data process and documentation flow for smooth and timely enrollment and credentialing processes. Be the subject matter expert on variations of patient access to PBM, Managed Care Organizations, and government agencies.

Research and Reporting

• Assists the pharmacy staff in all revenue integrity operations activities of the pharmacy to optimize customer satisfaction and profitability of the pharmacy.
• Navigate across multiple computer systems to respond to questions from external and/or internal partners and communicate in a friendly, welcoming, and professional manner.
• Track and report data including number of applications, enrollments, and assistance of all stakeholders. Present enrollment processes, statuses, and impacts to multiple internal stakeholders as patient access is of upmost importance to patient care. Track and report all revenue received due to successful Medicaid enrollment.
• Coordinate, compile and oversee the management of third-party external reviews for Medicare and Medicaid lines of business.

Additional Responsibilities

• Demonstrates proficiency in cross-functional areas across the system, including utilizing databases such as Mckesson, EnterpriseRx, and the Medicare websites and affiliated websites and portals.
• Researches to stay informed of all contractual activities and requirements as it relates to Fairview Pharmacy Services set up at the national and local level and provides updates to operational leaders and senior management of any Medicare or third-party payor changes that may adversely impact Fairview Pharmacy.
• Monitors the Medicare website for any updates to ensure that our accounts and processes are compliant with Federal and State requirements.
• Serves as subject matter expert on ad-hoc projects to support strategic Pharmacy operation activities.

Organization Expectations, as applicable:

• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
• • Partners with patient care giver in care/decision making.
• Communicates in a respective manner.
• Ensures a safe, secure environment.
• Individualizes plan of care to meet patient needs.
• Modifies clinical interventions based on population served.

• Provides patient education based on as assessment of learning needs of patient/care giver.

• Fulfills all organizational requirements

• Completes all required learning relevant to the role
• Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures, and standards.
• Fosters a culture of improvement, efficiency, and innovative thinking.
• Performs other duties as assigned

Minimum Qualifications to Fulfill Job Responsibilities:

Required

Education

• Associate's degree; or
• In lieu of degree, at least 2 years health care related experience

Experience

• 2 -3 years, including part of a team, supporting complex business processes.
• Excellent written communication skills, with demonstrated ability to work with all levels of management and staff across a complex organization.
• Excellent organization skills

Preferred

Education

• Bachelor's degree or Associate's degree.

Experience

• 1 years related experience with insurance company/payor or health care provider system.
• Advanced understanding of Compliance guidelines related to Medicare and Medicaid (for all 50 states) and local and national Managed Care Organizations
• Advanced knowledge of Medicare filing requirements
• Advanced knowledge of complex organization mapping

License/Certification/Registration

• CPhT – Certified Pharmacy Technician or commitment to attain certification within an agreed upon reasonable timeframe

Qualifications:

$62, $88,504.00 Annual