Reimbursement Specialist

at  Bayshore HealthCare

Under the supervision of the Reimbursement Team Lead/Manager, the Reimbursement Specialist will provide drug coverage support to physicians and patients, follow up on submissions pertaining to obtaining coverage through private and provincial drug plans, ensure patients have access to their prescribed treatments in a timely manner, act as a resource to physicians who are prescribing this medication and provide continuous support for patients for renewals, and coverage changes.

QUALIFICATIONS

• Minimum 2 years of Canadian public and private reimbursement navigation and advocacy experience, within a patient program environment, ideally with PA/SA drugs for chronic diseases.
• Excellent written and verbal communication skills in English.
• French is considered an asset but not required.
• Understanding of provincial and private coverage criteria
• Familiarity with the Special Authorization process for both public and private insurance.
• Strong computer and software skills: Excel, Word, Outlook, Adobe Acrobat, CRM database entry, VOIP telephony, web portals, teleconferences, web-based meetings, Kroll and/or other pharmacy-related software systems
• Ease with working independently, “playing detective,” making decisions using sound judgment, and meeting deadlines.
• Ease with working in a paperless environment.
• Familiarity with PIPEDA and how it applies in a confidential patient environment.

• Gather all pertinent and appropriate information from the chart to complete the necessary forms (private and/or provincial insurance) in a concise, organized and professional manner
• Liaise and advocate with insurance providers and provincial governments as necessary to determine coverage options
• Keep detailed notes in the patient’s electronic chart
• Follow-up/advocate until a decision is received to secure coverage for the patient
• Completes and/or reviews Prior Authorization (PA) or Special Authorization (SA) forms prior to submission to insurers
• Proactively offer financial assistance for patients
• Act as a resource for program stakeholders, which include physicians, nurses, patients and clinics and the client
• Assist with data integrity/rounds as required
• Assist the Specialty Drug Care Program in maintaining federal, provincial, and local laws, accrediting body standards, and Policies and Procedures (P&Ps)
• Communicates with patients regarding their third party insurance provider, or ODB, to resolved billing issues
• Communicates with patients’ third party plans, or ODB, to troubleshoot rejected claims
• Assists the pharmacist in entering prescriptions into the prescription software (Kroll), and filling/billing such prescriptions
• Participate in ongoing internal and/or external continuing education activities
• Adhere to Bayshore Policies and Procedures
• Participate in quality activities and continuous improvement initiatives in keeping with the company’s Quality Management System
• Employee will maintain relevant level of knowledge of ICH (International Conference on Harmonization), GCP (Good Clinical Practice) and Health Canada GVP (Good Pharmocovigilance Practices) guidelines appropriate to their hired role which is to be provided at time of hire and annually. With this knowledge the employee will perform the work as required by their assigned function and will be provided with regular updates as required.
• Participates in proactive Health & Safety activities while performing all duties. Is responsible to notify immediate Supervisor of any Health & Safety risks or concerns. Responsible for completing Accident Reports for all direct reports who injure themselves on the job, within 24 hours of the incident.
• Maintains confidentiality of client and corporate information and discusses same only with appropriate Bayshore personnel
• Complete other tasks as requested
  Job Qualification