Pharmacy Practice Specialist-Benefits Investigation and Prior Authorization

The Ambulatory Care Pharmacy Practice Specialist within the Pharmacy Benefits Investigation and Prior Authorization Team provides comprehensive pharmaceutical care services to patients seen in UI Health Care Ambulatory Care Pharmacies and clinics. The Pharmacy Practice Specialist plays a key leadership role in supporting and optimizing the operations of the Benefits Investigation (BI) and Prior Authorization (PA) team. This role collaborates closely with coordinators team leads and multidisciplinary partners to enhance processes drive quality improvement and implement innovative solutions. The practice specialist serves as a subject matter expert and resource to team members while helping to ensure timely and accurate insurance-related workflows in alignment with payer requirements and organizational goals. This role will have direct supervision of revenue cycle representatives in coordination with the technician supervisor. This role also plays a critical part in supporting the ongoing development standardization and strategic growth of the central prior authorization program across service areas.

Human Resource Management

• Direct oversight and supervision of revenue cycle representatives in coordination with Technician Supervisor
• Provide daily oversight guidance and operational support to the BI and PA team.
• Serve as a go-to resource for complex or escalated benefit investigation and authorization scenarios.
• Serve as a clinical resource for medication related questions from team members.
• Provides staff feedback and supports Human Resources initiatives in a positive manner.
• Provide assistance with hiring of benefits investigation and prior authorization staff and students including candidate evaluation interviewing and onboarding
• Develops manages optimizes and evaluates the performance of staff. Ensures staff are compliant with policies procedures regulations and competencies.
• Assists with providing performance related feedback and coaching to staff members.
• Meets with staff routinely to advance engagement and support.
• Reviews errors and provides staff coaching consistent with a Just Culture environment.
• Oversees daily operations to ensure adherence to policies and procedures.
• Engages staff in meeting ambulatory care and department goals.
• Creates an environment that encourages high performance accountability and teamwork.

Therapeutic Drug Monitoring (TDM)

• Completes a comprehensive patient assessment which includes evaluation of the patients medications and an evaluation of the patients medical history.
• Evaluates all prescription orders to ensure the appropriateness of the following:
  • Indication for use
  • Dose
  • Route of administration
  • Drug interactions
  • Dose adjustments for organ dysfunction
  • Physical and therapeutic incompatibilities
  • Drug-induced side effects and adverse reactions
  • Potential drug misuse or abuse
  • Use of the most cost-effective therapy
  • Duplicate therapy
• Ensures pharmacokinetic assessment of drug dosing on targeted patients through:
  • Clinical assessment of patients and desired therapeutic endpoints
  • Preparation of formal dosing recommendations
• Communicates with prescribers about patient medication needs.
• Conducts review of patient profiles and updates as needed based upon findings at time of patient visit.
• Provides appropriate drug information to other healthcare professionals.
• Confirms/clarifies (assesses) all patient drug allergies noted in the medical record.
• Participates in collecting and documenting medication histories on patients.
• Evaluates patient compliance with prescribed medication therapy and identifies problems that may lead to partial or noncompliance.
• Utilizes appropriate resources and coordinates the resolution of financial concerns/burdens with department financial counselors.
• Participates in the facilitation of continuity of care for patients when transitioning from one setting to another.

Documentation of Patient Care Activities Performed

The pharmacist provides pharmacy-related services through sharing of information with other members of the healthcare team via documentation within the patient medical record and other on-line reporting systems. Examples of documentation may include:

• Patient drug allergies and patient-specific height and weight information.
• Medication histories.
• Medication counseling to patients.
• Interventions with prescribers and other healthcare providers.
• Patient interactions those that occur in the clinic and when the patient is located elsewhere (e.g. at home as an inpatient in the Ambulatory Care Pharmacy).
• Drug dosing recommendations made to prescribers.
• Drug Use Evaluation Program activities.
• Steps taken to identify evaluate or avoid adverse drug reactions.
• Prescription billing information including prior authorization status.

Patient Communication and Interactions

The pharmacist must provide a high level of customer service and educate patients on the pharmaceutical care services offered including the following:

• Medication history.
• Patients drug allergy history.
• Patient teaching classes (where appropriate).
• Medication counseling.
• Communicating patient information to local healthcare providers involved with the patients care to ensure appropriate continuity of care.
• Providing support for prescription billing (e.g. benefits investigation prior authorization claim processing etc.).

Enhanced Patient Care Services

The pharmacist assumes the role of patient advocate for all concerns associated with drug therapy. The pharmacist shall position themself to positively influence therapeutic decisions which will affect patients and their care. Participation in hospital-wide programs intended to improve care (e.g. the Drug Use Evaluation Program and Adverse Drug Reaction Reporting Program) serves as a valuable quality-of-service surveillance tool and promotes healthcare provider education.

• Follows-up on any medication system problems such as:
  • Unclear or inappropriate prescription orders
  • Cost effective drug therapy
  • Prescription for non-formulary products
• Carries out as appropriate Medication Use Evaluation Program initiatives through active prescriber intervention and education.
• Serves on intra- and interdepartmental committees task forces and teams as required.

Revenue Cycle Management

• Assists patients and staff with troubleshooting insurance claim issues benefits investigation and enrollment of patients into pharmacy services.
  • Communicate with patients pharmacists and/ or providers to gather relevant demographic information.
  • Initiate and follow through for required prior authorizations.
  • Assist with copay/coinsurance assistance when applicable.
• Communicates with patients insurance companies credit/collections for payment acquisition pre-authorization and to resolve patient account inquiries.
• Appeals/troubleshoots claim payments and/or denials using available resources.
• Monitors compliance standards and policies to ensure UI Health Care receives full and accurate reimbursement for services in compliance with payor rules and regulations.
• Identifies workflows and best practices to improve the billing process.
• Analyzes and prepare routine reports to identify trends and aid in making strategic decisions.
• Serve as a liaison with pharmaceutical manufacturers payers and external stakeholders to enhance communication and address barriers related to benefit verification and authorization requirements.
• Represent the team in collaborative meetings with internal partners such as pharmacists prescribers and revenue cycle teams.
• Contribute to the success and expansion of the central prior authorization program by supporting standardized workflows cross-team alignment and sustainable infrastructure.
• Partner with leadership and key stakeholders to identify opportunities for program growth and improved service delivery across departments.

Educational Services

University of Iowa Health Care is a teaching institution; therefore the pharmacist is responsible for the education of others about appropriate medication use and billing practices and should serve as a role model. The pharmacist will participate in education services which may include:

• Serving as preceptor for pharmacy students and pharmacy residents.
• Presenting in-service educational programs to staff nurses physicians and other colleagues on the healthcare team.
• Presenting at and/or participating in other educational programs sponsored by the Department of Pharmaceutical Care the College of Pharmacy other UIHC or UI departments and state and national organizations.
• Conducting educational classes for pharmacy students and pharmacy residents.
• Conducting patient education classes about the proper use of medications.
• Serving as mentor and role model for other pharmacist practitioners within the department particularly those who provide ambulatory care services.
• Assists in the onboarding training and mentoring of new staff members.
• Support ongoing education efforts to ensure staff remain up to date on payer trends regulatory requirements and process changes.
• Develop deliver and maintain training materials and job aids in collaboration with managers coordinators and team leads

Other

• Collaborate with coordinators and team leads to develop implement and maintain a comprehensive quality assurance program for prior authorization workflows.
• Monitor performance metrics and trends to identify gaps and drive continuous improvement.
• Lead initiatives to streamline and standardize BI/PA processes for efficiency and accuracy including leveraging of artificial intelligence.
• Lead and coordinate team efforts related to payer-mandated or manufacturer-driven formulary changes ensuring alignment across service lines and continuity of care for patients.
• Support cross-functional projects and initiatives as assigned by department leadership.
• Completes and maintains compliance with all competencies and educational requirements.
• In collaboration with Ambulatory Care Pharmacy leadership lead expansion efforts of medication prior authorization services across UI Health Care.
• Assists with the evaluation and implementation of new products/technology policies and procedures.
• Performs other duties as assigned.