GENERAL SUMMARY: Under the direction of the Department Director or Manager, coordinates and facilitates operations in key department areas such as automation and information services, pharmaceutical waste management, regulatory readiness, purchasing and inventory control, controlled substances diversion monitoring, and other duties and responsibilities as assigned. Approximately 65% of responsibilities are related to automation and associated activities. Works closely with pharmacy, nursing, and other multidisciplinary teams within each business unit.
* This role supports patients' medication access by managing infusion and injection benefit claims, ensuring financial viability, and addressing affordability concerns throughout the care journey.
* Claims Authorization Support: Efficiently validate insurance coverage and determine when medication prior authorization is required, ensuring accuracy and compliance with insurance guidelines to support timely and appropriate reimbursement.
* Product Selection and Payer Formulary Review: Identify appropriate formulary medications, NDCs, and corresponding HCPCS codes to ensure accurate prior authorization, billing, and reimbursement. Collaborate with pharmacists, healthcare providers, insurance companies, and third parties to resolve payer issues, minimize claim denials, and optimize service delivery for improved patient outcomes.
* Documentation and Compliance: Review electronic medical records to collect pertinent information needed for submitting, appealing, and resolving prior authorizations. Document all activities in compliance with institutional policies, payer requirements, and regulatory standards. Stay informed of changes in insurance policies, payer requirements, and regulatory standards related to medication benefits to ensure compliance and provide accurate information to patients and stakeholders.
* Stakeholder Communication and Engagement: Foster effective communication between care teams, providers, infusion patient access hub and central authorization teams, and external stakeholders to promote collaboration, optimize service delivery, and ensure seamless patient experience.
* Support for Infusion Patient Access Hub Pharmacist and Pharmacy Revenue Cycle team: Collaborate with pharmacy Hub Team and Revenue cycle team to select appropriate formulary medications and optimize pharmacy initiatives.
* Follow-Up and Problem Solving: Conduct proactive follow-ups on prior authorizations and claims status. Identify and address root causes of medication access barriers and provide effective solutions to resolve any issues.
* Claims Management and Appeals: Support audits by reviewing billing and reimbursement activities, monitor appeals and denied claims and support Hub pharmacist as needed with appeals process and address discrepancies to maximize reimbursement and financial accuracy.
* Process Optimization: Identify opportunities for improving infusion patient access hub workflows related to medication access, prior authorizations, and claims resolution. Collaborate with pharmacists and care teams to implement process enhancements that streamline operations and improve service delivery.
* Regulatory Knowledge: Stay informed about changes in medication benefits, insurance policies, and regulations to ensure compliance and provide up-to-date information.
EDUCATION/EXPERIENCE REQUIRED: Requires high school diploma or G.E.D. equivalent. Requires at least two (2) years of experience as an inpatient pharmacy technician (for inpatient setting) OR two (2) years of experience as a pharmacy technician for all others. Two (2) years of experience with automated pharmacy dispensing systems preferred. PC skills as needed to perform job functions as assigned. Strong verbal/written skills; availability for on-call system support; highly analytical ability to solve complex technical problems. Ability to work designated shifts, including weekends and holidays. Ability to function in a fast-paced environment with established time constraints. Flexibility to deal with ever-changing health care environment. Ability to effectively manage multiple projects.
Additional qualifications:
* Minimum of 2 years' experience in a pharmacy setting, with experience in medication benefits management, specialty pharmacy, or a related field preferred
* Strong working knowledge of insurance benefit structures, payer policies, and access tools (preferred).
* Previous experience in an infusion center or home infusion pharmacy and/or processing prior authorizations is highly desirable
* Certification in pharmacy revenue cycle management by American Society of Health-System Pharmacists (ASHP) required within 6 months of hire
Skills:
o Strong communication and interpersonal skills
o Ability to multitask and handle high-stress situations
CERTIFICATIONS/LICENSURES REQUIRED: Valid State of MI pharmacy technician licensure required.
Additional Information
- Organization: Corporate Services
- Department: Pharmacy Admin - Product Line
- Shift: Day Job
- Union Code: Not Applicable
Henry Ford Health System
Dec 06, 2025