Reimbursement Specialist Senior - Remote
Virginia Commonwealth University Health Systems, Richmond, Virginia, United States, 23214
Overview
The Reimbursement Specialist Senior serves as an advanced-level specialist, handling the most complex prior authorizations, insurance appeals, and patient assistance cases pertaining to high-cost medications that require prior authorization. This role provides guidance to peers, ensures adherence to compliance and turnaround standards, and acts as a subject matter expert for the Reimbursement Specialist team. Essential Job Statements
Manage complex or high-priority prior authorizations and appeals across multiple clinics.
Provide guidance and mentorship to Reimbursement Specialists on best practices and workflow efficiencies.
Collaborate with providers, nursing staff, and the Patient Assistance Program (PAP) team to ensure accurate and timely access to medications.
Conduct benefit investigations and gather supporting clinical documentation for challenging cases.
Track and analyze Patient Assistance (PA) metrics, approvals, and denials to identify trends and improvement opportunities.
Assist in training new team members and provide ongoing education to peers.
Participate in special projects to improve departmental operations and patient care.
Ensure compliance with departmental and health system policies and regulatory requirements.
Serve as a point of escalation for complex PA or patient access issues.
Support the supervisor in monitoring workload distribution and workflow optimization.
Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the Department. Provides assistance to team members. Accepts alternate assignments, as required.
Patient Population
Not applicable to this position. Employment Qualifications
Required Education:
High School Diploma or equivalent Preferred Education:
Associate's Degree or higher in Business, Healthcare Administration, or related field Licensure/Certification Required:
Current certification by the Pharmacy Technician Certification Board (PTCB); Current licensure with the Virginia State Board of Pharmacy Licensure/Certification Preferred:
Additional certifications in reimbursement or pharmacy administration a plus Minimum Qualifications Years and Type of Required Experience Minimum of two (2) years of experience as a Reimbursement Specialist or equivalent role Demonstrated ability to handle complex PAs, appeals, and PAP cases Other Knowledge, Skills and Abilities Required: Strong problem-solving, analytical, and communication skills Ability to handle multiple priorities in a fast-paced environment Cultural Responsiveness Other Knowledge, Skills and Abilities Preferred: Strong leadership and communication skills Ability to handle multiple priorities and high-volume workload Working Conditions
Periods of high stress and fluctuating workloads may occur. General office environment. May be exposed to high noise levels and bright lights. May have periods of constant interruptions. Prolonged periods of working alone. Physical Requirements
Physical Demands:
Lifting/ Carrying (0-50 lbs.), Bending Work Position:
Sitting, Walking, Standing Additional Physical Requirements/ Hazards
Physical Requirements:
Manual dexterity (eye/hand coordination), Perform shift work, Hear alarms/telephone/tape recorder, Reach above shoulder, Repetitive arm/hand movements, Finger Dexterity, Color Vision, Acuity - far, Acuity - near Hazards: Mental/Sensory -Emotional
Mental / Sensory:
Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking Emotional:
Fast-paced environment, Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Noisy Environment, Able to Adapt to Frequent Change EEO/Employer/Veteran/Protected
Veteran/41 CFR 60-1.4.
#J-18808-Ljbffr
The Reimbursement Specialist Senior serves as an advanced-level specialist, handling the most complex prior authorizations, insurance appeals, and patient assistance cases pertaining to high-cost medications that require prior authorization. This role provides guidance to peers, ensures adherence to compliance and turnaround standards, and acts as a subject matter expert for the Reimbursement Specialist team. Essential Job Statements
Manage complex or high-priority prior authorizations and appeals across multiple clinics.
Provide guidance and mentorship to Reimbursement Specialists on best practices and workflow efficiencies.
Collaborate with providers, nursing staff, and the Patient Assistance Program (PAP) team to ensure accurate and timely access to medications.
Conduct benefit investigations and gather supporting clinical documentation for challenging cases.
Track and analyze Patient Assistance (PA) metrics, approvals, and denials to identify trends and improvement opportunities.
Assist in training new team members and provide ongoing education to peers.
Participate in special projects to improve departmental operations and patient care.
Ensure compliance with departmental and health system policies and regulatory requirements.
Serve as a point of escalation for complex PA or patient access issues.
Support the supervisor in monitoring workload distribution and workflow optimization.
Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the Department. Provides assistance to team members. Accepts alternate assignments, as required.
Patient Population
Not applicable to this position. Employment Qualifications
Required Education:
High School Diploma or equivalent Preferred Education:
Associate's Degree or higher in Business, Healthcare Administration, or related field Licensure/Certification Required:
Current certification by the Pharmacy Technician Certification Board (PTCB); Current licensure with the Virginia State Board of Pharmacy Licensure/Certification Preferred:
Additional certifications in reimbursement or pharmacy administration a plus Minimum Qualifications Years and Type of Required Experience Minimum of two (2) years of experience as a Reimbursement Specialist or equivalent role Demonstrated ability to handle complex PAs, appeals, and PAP cases Other Knowledge, Skills and Abilities Required: Strong problem-solving, analytical, and communication skills Ability to handle multiple priorities in a fast-paced environment Cultural Responsiveness Other Knowledge, Skills and Abilities Preferred: Strong leadership and communication skills Ability to handle multiple priorities and high-volume workload Working Conditions
Periods of high stress and fluctuating workloads may occur. General office environment. May be exposed to high noise levels and bright lights. May have periods of constant interruptions. Prolonged periods of working alone. Physical Requirements
Physical Demands:
Lifting/ Carrying (0-50 lbs.), Bending Work Position:
Sitting, Walking, Standing Additional Physical Requirements/ Hazards
Physical Requirements:
Manual dexterity (eye/hand coordination), Perform shift work, Hear alarms/telephone/tape recorder, Reach above shoulder, Repetitive arm/hand movements, Finger Dexterity, Color Vision, Acuity - far, Acuity - near Hazards: Mental/Sensory -Emotional
Mental / Sensory:
Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking Emotional:
Fast-paced environment, Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Noisy Environment, Able to Adapt to Frequent Change EEO/Employer/Veteran/Protected
Veteran/41 CFR 60-1.4.
#J-18808-Ljbffr