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INTRODUCTION

The Lead Pharmacy Access Specialist is responsible for overseeing and streamlining patient access to essential medications within Fairview Pharmacy Services. This role involves managing complex payer policies, verifying insurance benefits, and removing barriers to care through collaboration with patients, payers, and clinical teams. The Lead Pharmacy Access Specialist also guides patients through financial assistance options, coordinates high-cost drug procurement, and serves as the primary escalation point for complex access issues. Additionally, this position leads process improvement initiatives, maintains key relationships with stakeholders, and supports pharmacy staff through training and development. By fostering efficient, compassionate access to pharmacy services, the Lead Specialist ensures that patients receive timely, affordable care that meets their needs and supports positive health outcomes.

ROLE AND RESPONSIBILITIES

Lead responsibilities:

• Drive Process Improvement Initiatives: Identify and implement process improvements to streamline patient access workflows, reduce turnaround times, and increase efficiency in the authorization process.
• Serve as Escalation Point for Complex Cases: Provide guidance and solutions for challenging cases, including appeals for denied claims, coverage exceptions, and negotiating with third-party payers.
• Identify and escalate issues if deemed beyond scope.
• Train and onboard new employees. Lead orientation and training for new staff members, ensuring they understand access protocols, payer policies, financial assistance resources, and best practices for patient support.
• Establish and Manage Key Stakeholder Relationships: Build and maintain relationships with payers, specialty pharmacies, manufacturers, and financial assistance organizations to facilitate patient access to medications.
• Optimize Financial Assistance Programs: Develop and implement strategies to maximize patient enrollment in financial assistance programs and identify additional resources.
• In partnership with the Pharmacy Leader and other stakeholders, provide workflow management of the day-to-day operations in assigned pharmacy and/or clinical service area, driving patient care excellence while ensuring achievement of organizational goals.
• Coordinates the daily workflow and solves issues which need resolution within a department, in a peer-to-peer relationship and as a liaison with leadership. The focus is to strengthen and enhance the work climate and workflow. The lead has a high level of technical expertise and displays role model competency in knowledge, communication and experience while acting as the primary peer resource.
• The Lead will skillfully use interpersonal, customer service, problem solving and collaboration skills to support and influence operational objectives. Proficient in their knowledge of responsibilities, the Lead will be capable of assisting and resolving exceptions commonly referred to the supervisor for resolution.

General responsibilities:

• Perform verification of insurance benefits, analysis, payer policies, identify any potential access issues, and removing barriers to care across Fairview Pharmacy Services.
• Assist in resolving access issues with payers and provide information and expertise to other departments.
• Assess patients’ payor source and clinical information to identify appropriate site to provide care for patient (home infusion, outpatient infusion therapy, or specialty pharmacy) and coordinate with staff as appropriate.
• Screen patients for financial assistance eligibility by gathering financial information including income, assets, and estimates of charges for service, as appropriate.
• Support pharmacy services with requests from revenue cycle (coding, billing, etc.) regarding infusions and clinic administered medications.
• Maintain current knowledge of payer requirements and general admitting practices including use of online verification applications and initial and ongoing training.
• Coordination and authorization of payer mandated white bagging when required by MN State Law (not currently in effect).
• Understand all third party and Medicare/Medicaid regulations and billing guidelines as they pertain to pharmacy and medical benefits. Including Coordination of Benefits and copay assistance.
• Coordinate with outside facilities on prior authorization and access as needed for MHFV providers.
• Research to find other programs for payment and/or negotiate with providers and third-party payers to provide coverage or exceptions.
• Partner with potential international and self-pay patients on any financial or service needs related to their pharmacy care.
• Provide financial counselling and support for patients as needed during their treatment communicating options for financial assistance as appropriate; answer related questions to ensure patients’ understanding of their benefits.
• Explain patient charges and/or insurance benefits (medical & pharmacy) and communicate expectations of financial responsibilities as it relates to access issues.
• Advising patients on route to access if unable to be serviced within FPS (limited distribution, payor carve out, benefit design, etc.)
• Expedite patient access to high-cost medications by identifying and resolving barriers on behalf of clinic care teams, including submitting and following prior authorizations/appeals, alternate funding for claim appeals, and assisting patients with financial assistance program on out-of-pocket costs.
• Understand the patient journey, support resources available, and strategies to shape ongoing patient relationships.
• Communicate expectations, timing, and process capability to pharmacy, patients, caregivers, and clinics.
• Drug care coordination working with clinics and various Fairview Pharmacy Services teams to allow seamless transition and access to high-cost medications to allow for best patient experience.
• Meet with clinic staff regularly to foster relationship-building and represent Fairview Pharmacy Services.
• Assist care teams with Letters of Medical Necessity and maintain template library.
• Coordinate with Care Teams on high level appeals across FPS (Court of Appeals).
• Act as an advocate for ambulatory pharmacy services, including, but not limited to specialty pharmacy, home infusion pharmacy, compounding pharmacy, acute care and explaining our offered services (all FPS locations).
• Use various reports and data across FPS to identify, support and implement changes to current processes to facilitate communication and service between patient, provider, and pharmacy teams to ensure accurate and timely delivery of care.
• Support Pharmacy Services and organization to on-board high-cost new drug therapies to ensure appropriate access for patients and education to appropriate FPS teams.
• Work as Pharmacy Services Access expert to teach and train direct pharmacy staff on broad access issues (Subject Matter/Situational Expert and Educational resource for Pharmacy Services).
• Serve as a resource to the affiliations, staff, and physicians regarding Fairview Pharmacy Services. Assist with the coordination of services by communicating effectively and in a timely manner with others.
• Establish relationships with industry representatives and reimbursement managers to maintain current knowledge on available financial assistance programs.
• Identify and escalate issues if deemed beyond scope.

BASIC QUALIFICATIONS

• B.S./B.A. in business or healthcare related field
• 5 years of revenue cycle, financial counseling, pharmacy access services, or contracting experience in a healthcare or insurance organization
• Communication skills, interpersonal skills, adaptability are critical
• Willingness to work in a fast-paced environment, work independently, to grow and develop

PREFERRED QUALIFICATIONS

• 7 years of revenue cycle, financial counseling, pharmacy access services, or contracting experience in a healthcare or insurance organization
• Experience in pharmacy, working with specialty infusion, home infusion, pharmacy medications, prior authorizations, and/or coordinating work with multiple stakeholders
• Pharmacy Technician MN Registered as Pharmacy Technician with the MN State Board of Pharmacy. If Minnesota Board of Pharmacy registration on or after 1/1/2013, must have a certificate of completion from a MNBOP approved employer based or vocational/technical training program
• Pharmacy certification with the Pharmacy Technician Certification Board

COMPENSATION

• $29.29 - $41.35 Hourly