Pharmacy Revenue Integrity Specialist

Scope of Position

The Ohio State University Wexner Medical Center is committed to improving access and service to customers. The Pharmacy Revenue Integrity Specialist (PRIS) position serves as subject matter content expert and change agent with an in-depth knowledge of managing and resolving medication denials and appeals management. This process includes, but is not limited to, conducting comprehensive clinical appeals, developing a robust understanding and ability to recognize denial payor patterns, actively leads and participates in communication of denial trends to staff, and assistance with internal and external clients to expedite appeal resolution and advocate for successful outcomes. This information is important to the organization to ensure the appropriate information is available and used for successful billing and denial resolution.

Position Summary

The PRISs responsibilities include performing in-depth, comprehensive clinical reviews of denial records, submitting initial appeals and when needed, subsequent levels of appeal and follow up management. They act by developing a deep understanding of payor denial patterns, serving as the educator/liaison to providers, prior authorization teams and support staff. The PRIS acts as the liaison to third party insurance payors to provide optimal reimbursement and other billing/payment issues or questions by resolving technical denials related to medication charges. PRIS s must be able to navigate the electronic medical record system to obtain and interpret pertinent medical information relevant to the denial management for medication use. The PRIS participates in departmental processes for improvement and training of new and existing Medication Access staff. In addition, the PRIS may be required to communicate with physicians, payors, patients, and other customer groups. PRIS s will also be expected to be involved with process improvement and internal quality reviews.

Minimum Qualifications

Bachelors degree and at least 6 years' experience preferred in OSUWMC Medication Access Team as a Clinical Financial Case Manager II/III preferred. Experience in interpreting insurance benefit information and completing prior authorization process is preferred. Knowledge of medical terminology is preferred. Excellent interpersonal skills are desired, especially the ability to communicate and work effectively with a team. Employee must be highly organized, detail oriented, and able to manage multiple projects at a time. Some professional licensures or certification is required for employment.