Program Manager - Pharmacy

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

About Duke HomeCare & Hospice

Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.

Job Title: Program Manager - Pharmacy

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

JOB SUMMARY:  The Infusion Patient Eligibility Program Manager will serve as the primary resource liaison to ensure infusion patients are set up with proper required documentation, timely approvals, and perform troubleshooting for a streamlined transition from all care providers within Duke Health to continue home care proactively preventing financial risk and delayed patient care.  Responsible for primary communication with intra- and interdepartmental customers.

 MAJOR JOB RESPONSIBILITIES:

• Manage for the infusion department finalizing authorizations process and coordination between referral center, finance, and provider offices for timely, accurate, and streamlined approvals.
• Monitor and serve as primary resource for questions related to verification, authorization, and finance affecting approvals and billing.
• Facilitate and participate in meetings to address challenges and obstacles in the onboarding process for specialty patients, and implement process improvements.
• Oversee and support the verification and authorization procedures for specialty patients.
• Supervise the authorization queue for new and refill requests of specialty patients.
• Assist and review rejected pharmacy claims for resolution.
• Conduct random chart audits for new referrals and existing patients to monitor for documentation accuracy.
• Evaluate the timeline from receiving specialty referrals to patient onboarding, and identify opportunities for improving turnaround times.
• Review policy updates and health insurance criteria to enhance the onboarding process for specialty patients.
• Liaise with providers' offices and check patient portals for additional documentation required for home infusion or health insurance reviews.
• Coordinate with home health agencies to obtain necessary nursing notes and additional documentation for home infusion.
• Ensure all required documentation and authorizations are secured prior to patient onboarding to facilitate initial clean claim processing by the billing department.
• Monitor claims on hold and gather missing information to enable the billing department to process claims.
• Track denial reports and obtain necessary documentation for diagnosis-related denials.
• Assist in contacting patients to request updates on their health insurance plans for coordination of benefits.
• Monitor ineligibility reports, check patient portals, and contact patients for updated health insurance information.
• Follow up with various departments, provider offices, referral sources, home health agencies, and patients to obtain missing documentation for the onboarding process.
• Consult with the home infusion legal department to verify and proceed with requests from law firms.
• Obtain and send required documentation for Medicare audits, law firms, and health insurance companies.
• Work with leadership to ensure we are meeting state, federal, and accrediting agency requirements for patient documentation and billing.
• Monitor the National Council for Prescription Drug Programs (NCPDP) pharmacy queue and assist with resolving rejected pharmacy claims.
• Collaborate daily with DHCH departments, including finance/billing and referral departments, to ensure alignment with company policies and payer regulations.
• Lead and assist in the revision and development of new processes.
• Perform additional duties as assigned.

Minimum Qualifications

Education

Work requires communication, analytical, and organizational skills generally acquired through completing a bachelor's degree program.

Experience

Work requires the ability to plan and administer programs and direct program activities within a specific functional area, generally acquired through four years of related experience.

OR ANY OTHER EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE

Knowledge, Skills, and Abilities

SUPERVISION BUDGET PROJECTIONS ANALYZE TRENDS CUSTOMER SERVICE

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends onthe robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends onthe robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.