Medication Access Coordinator MG -Specialty GI

Shift: Full Time, Days

Reporting to the Specialty Management team, the Ambulatory Specialty Medication Access Coordinator works with Specialty nurses, physicians, patients, their representatives, insurance carriers and employers to determine benefits eligibility, benefits verification, and prior authorization requirements for high cost medications used in the Medical Group Specialty as well as in home or infusion clinic. The Ambulatory Specialty Medication Access Coordinator screens registration data for compliance to ensure optimal reimbursement for high cost medications and assists with denials and failed claims to ensure maximum reimbursement.

1. Expedites authorizations for high dollar medications that are given in the office, home, or infusion clinic and exceeds patients’ expectations for obtaining needed medications and therapies.

2. Works with insurance carriers to determine patient’s eligibility and benefits for high cost pharmaceuticals though medical coverage or pharmacy benefit depending on patient’s plan. Performs benefit verifications and pre-authorization requirement to obtain medications and/or prior authorization for patients.

3. Works with patient’s specialty pharmacy to obtain medications if patient’s plan so requires. Researches patient chart to obtain and document medical necessity working with prescribing physician when needed to obtain prior authorization. Prepare letters of medical necessity drafts for prescribing physician as needed.

4. Reviews and analyzes all required demographic, insurance/financial, and clinical data procured by patient intake and registration areas necessary to obtain high dollar medications while maximizing reimbursement for those drugs and therapies. Resolves all issues including obtaining information and signatures on documents required by the patient’s insurance carrier. Interacts, via telephone and in person, with patients, their representatives, physicians, physician’s office staff, employers, and others, and reviews new and previously recorded patient, insurance and procedural information. Electronically records all phone interactions and records resolution to follow-up items in a timely manner. Follows HIPAA, payer, and applicable regulations and standards.

5. Acts as a liaison between patients, physicians, and insurance companies to pre-authorize all medication therapies per insurance contract requirements. Notifies patients, physicians and ancillary departments regarding therapies that are potentially not covered and recommends enrollment into patient assistance plans when applicable.

6. Assists with clinic workflow and improves patient care by collaborating with specialty nurses to prevent interruptions or delays in treatment due to insurance issues.

7. Researches denials including missing authorization, pre-determination or referral documentation. Works on denied accounts by assisting with appeals submissions. Identifies, researches, and secures authorization for unspecified, new or unlisted medications or treatments to procure payment from insurance carriers.

8. Utilizes EPIC Scheduling reports, reviewing specified physician ordered tests/ procedures/medications, ensuring the integrity of registration and CPT codes.

9. Serves as a team representative at NCH MG Specialty meetings and provides input and recommendations on documentation issues with the patient’s need as priority. Researches and analyzes case problems and participates in quality and process improvement initiatives as appropriate. Provides feedback into insurance carrier trends for specialty medication prescribing and authorization requirements.

10. Adheres to all Northwest Community Hospital standards, policies, and procedures and reports compliance concerns to management staff.

1. The level of knowledge normally obtained through the completion of four years of high school. Degree in healthcare preferred.

2. Minimum 1 year experience working with specialty pharmacies and insurance companies to obtain medications and prior authorizations.

3. Minimum of 2 years previous healthcare or related experience and familiarity with payer requirements, regulatory compliance requirements, HIPAA privacy and security requirements, medical terminology and general revenue cycle procedures required. Prior pharmacy experience preferred.

4. Ability to functionally navigate multiple computer software systems with accurate keyboard skills following computer security protocols.

5. The interpersonal communication skills necessary to interview and interact with customers, physicians and insurance carriers, to project a professional and compassionate concierge style of service.

6. Ability to work independently, exercising good judgment, and multi-task in a high stress, fast paced service environment with patients, physicians and insurance carriers.

7. Detail oriented with good analytical problem-solving skills to appropriately register patients and schedule patient procedures.

8. Ability to operate routine office equipment (facsimile, copiers, plate production, scanners, printers).

PHYSICAL REQUIREMENTS
1. Requires light physical effort. May require frequent periods of standing or walking. May require frequent lifting or moving of lightweight material, occasional moving or lifting of average weight material, or rarely lifting or moving heavyweight material.
2. The flow of work and character of duties involves normal mental and visual attention much or all of the time.
3. Ability to hear and speak over telephone.
WORKING CONDITIONS:
1. Conditions are acceptable. There is some risk to toxic substances and infectious diseases.

About Us
Serving Chicago's northwest suburbs since 1959, we are an independent, not-for-profit healthcare system dedicated to providing outstanding care in the communities we call home. Our comprehensive, patient-centered system of care has dozens of locations throughout the area.
Our award-winning care has been recognized on a national level. Some of our top awards include:

• America's 250 Best Hospitals™ Award recipient for three years in a row from Healthgrades®
• Magnet® designation for nursing excellence, received consecutively since 2006
• The Joint Commission's Gold Seal of Approval and Comprehensive Stroke Center designation

Our team includes:

• 4,000 employees
• 1,200 physicians on staff
• 200 primary are and specialty physicians

Annually, we treat an average of 20,000 inpatients and provide:

• 350,000 outpatient visits
• 76,000 emergency department visits
• 38,000 home care visits
• 2,700 newborn deliveries

A growing healthcare system
Over the years, we have continued to grow to meet the area's changing needs. Today, we're a world-class healthcare provider that combines compassionate care with a healing environment, cutting-edge clinical expertise and state-of-the-art facilities, including:

• A 509-bed hospital, including the South Pavilion with 200 private rooms
• The William J. and Marian H. Busse Center for Specialty Medicine, an eight-floor facility housing physician offices, medical specialty services and advanced diagnostic technology
• A Level III NICU, Level II Trauma Center and a dedicated pediatric emergency department
• Five Immediate Care Centers, in Buffalo Grove, Kildeer, Mount Prospect, Palatine and Schaumburg
• 23 physician offices in Arlington Heights, Buffalo Grove, Kildeer, Mount Prospect, Palatine, Rolling Meadows and Schaumburg
• Nine outpatient imaging locations that provide advancted pediatric emergency department
• Five Immediate Care Centers, in Buffalo Grove, Kildeer, Mount Prospect, Palatine and Schaumburg
• 23 physician offices in Arlington Heights, Buffalo Grove, Kildeer, Mount Prospect, Palatine, Rolling Meadows and Schaumburg
• Nine outpatient imaging locations that provide advanced imaging technology, including MRI, CT, ultrasound, X-ray and 3D mammography
• 13 clinical laboratory sites in seven suburbs and at the hospital
• 33-bed acute inpatient rehabilitation unit and seven outpatient rehabilitation centers
• The Wellness Center, a premier health and fitness center and spa on the NCH campus
• A full-service, retail pharmacy on the hospital campus

Primary Location: United States-Illinois-Arlington Heights

Work Locations: 1051 W Rand - NCHMG 1051 W Rand Rd Arlington Heights 60004

Job: Medical Group

Shift: Day Job

Employee Status: Regular