Medication Access Nurse

GENERAL SUMMARY:

Responsible for completing the necessary functions to improve patient access to medications by supporting the functions of inpatient and outpatient pharmacists. Proactively reviews and verifies patients' drug benefit information to ensure reimbursement requirements are met. Conducts insurance prior authorization requests. Coordinates patient care related to medication infusions/injections. Identifies opportunities for improving reimbursement from payers. Establishes collaborative working relationships with internal departments and external providers/insurance companies.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Performs multi-resource appointment scheduling for inpatient/outpatient diagnostic and therapeutic services received from providers and/or their staff.

3. *Obtains patient information including medical necessity/diagnosis, demographics, and pertinent clinical information as related to the procedure(s) scheduled. Collects and documents information beyond that listed in procedural questionnaire or therapy plan documentation based on critical assessment of patient history.

4. *Integrates physical, mental and cultural considerations in scheduling of patient procedure(s), coordinating services to ensure the Medical Center is patient ready on customer arrival and provides exemplary customer service to customers.

5. *Collaborates with physician office staff to educate the patient/patient representative on preparation and understanding of scheduled procedure(s); clearly communicates instructions to patient and/or patient representative.

6. *Reviews and evaluates outpatient orders received from the provider and/or their staff; uses clinical judgment /critical thinking to follow-up on appropriateness and completeness of provider orders as they relate to procedure(s) or medications ordered and transcribes the order(s) into the electronic system.

7. *Prepares and provides patients with an estimate, if one is warranted, for their expected services. Collects and/or counsels on expected payment due.

8. Responsible for understanding pharmacy agreements with insurance companies and ensuring use of contracts that Bryan Health accepts.

9. Navigates medication reimbursement to maximize revenue capture for high cost medications by completing necessary insurance authorizations.

10. Assists patients with the multiple avenues that are available for medication assistance based on their level of income and pharmacy insurance coverage (e.g. copay assistance, voucher, medication assistance, etc).

11. Communicates effectively with care providers to provide updates on test claims or follow-up actions.

12. Assists with the development and implementation of policies and procedures to ensure a seamless medication-related access for patients.

13. *Verifies third party insurance coverage from pre-registration, daily admissions and scheduling databases, updates appropriate software systems.

14. *Ensures that pre-certification and/or authorization and referral requirements have been completed by placing phone calls to insurance companies, physician offices, patients, and utilizing web based applications and/or internet resources; obtains clinical information from physician offices and/or Bryan system; contacts Health Information Management to obtain CPT and/or ICD-9 codes. Serves as a work resource and liaison to all areas mentioned.

15. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

16. Participates in meetings, committees and department projects as assigned.

17. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

EDUCATION AND EXPERIENCE:

Current Registered Nurse from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of one (1) year nursing experience to include extensive experience of hospital/health operations and general background in all areas of nursing practice required. Experience with medication infusions/injections preferred.