RxTriage Liaison (Infusion)
hace 15 días
Durham
Job Description This role is onsite in Durham, NC for the first 6-8 weeks of training. Once the new hire is fully stabilized, they will be able to work hybrid 2-3 days a week onsite. Job Purpose: The company is seeking a highly motivated, detail-oriented, and dependable Triage Liaison to support our rapidly growing healthcare provider administered (HCPA) medication operations. This role is responsible for receiving, assessing, and directing incoming prescriptions and HCPA referrals to the appropriate site of care – Hospital Outpatient Departments (HOPD), Ambulatory Infusion Centers (AIC), Home Infusion (HI), or external/contract pharmacies/agencies. This role also ensures patients are routed efficiently based on insurance requirements, patient preference, clinical needs, reimbursement feasibility, and operational capacity. The RxTriage Liaison acts as the first decision point in the referral workflow process and collaborates with pharmacy, nursing, intake, revenue cycle management, and clinical partners to ensure timely access to care. The RxTriage Liaison will support a specific specialty clinic/s or be part of a centralized intake team serving multiple clinics and disease states/diagnosis requiring infusion therapy. Key Responsibilities Referral Intake & Routing • Receive and review all incoming specialty and HCPA medication orders/referrals., • Evaluate referral type, diagnosis, therapy, urgency, payer requirements, patient preference/home-care eligibility and clinicals documentation to determine the correct pathway (HOPD, AIC, HI, external entities)., • Verify patient demographics, prescriber information, therapy details, and completeness of required documentation, • Identify whether medication is billable under medical or pharmacy benefits and route accordingly. Benefit & Eligibility Screening (Initial-Level Triage) • Conduct preliminary benefits review to identify:, • Coverage requirements (site-of-care mandates, white-bagging, brown-bagging, or specialty pharmacy restrictions)., • Whether therapy is eligible for in-house care vs. must be dispensed externally., • Potential red flags requiring escalation (e.g., no coverage, non-formulary status, narrow network)., • Communicate initial payer findings to the appropriate downstream teams (Intake Coordinator, Financial Coordinator, Pharmacy team, Partner, etc.). Clinical & Operational Assessment • Confirm whether required clinical documentation is present (labs, progress notes, treatment plans, diagnoses, etc.)., • Identify missing elements and request documentation from providers as needed for appropriate routing., • Assess operational considerations including:, • Product availability or procurement barriers, • Nursing service availability (for home infusion), • Infusion center capacity, • Ensure readiness before finalizing referral destination. Cross-Team Communication & Coordination • Serve as the central liaison between intake, pharmacy, clinical teams, ambulatory infusion centers, and home infusion services., • Communicate routing decisions clearly and promptly to:, • Pharmacy teams (internal and external), • Nursing coordinators, • Intake/pre cert teams, • Providers and clinic staff, • Ensure referrals move seamlessly into the correct workflow for benefits investigation, authorization, scheduling, and dispensing. Documentation & Compliance • Accurately record all triage actions, decision rationale, communications, and next steps in designated platforms (e.g., EMR, TRX, referral management systems)., • Maintain compliance with payer rules, infusion therapy standards, and site of care policies., • Support audits or quality reviews by ensuring documentation is complete and consistent. Patient Interaction • As needed, contact patients to clarify insurance, care preferences, or logistical considerations impacting routing., • Provide a high-touch, supportive experience when discussing site-of-care expectations or next steps. Additional Responsibilities • Collaborate with formulary or reimbursement specialists to identify preferred alternatives when necessary., • Support process improvement efforts to streamline triage and referral routing., • Assist with staff training on referral pathways, payer rules, and site of care policies. Skills: Strong interpersonal communication skills, ability to work independently and demonstrate good judgement, strong verbal and written communication, highly proficient in Microsoft Office particularly Excel and Word; able to quickly learn other software programs and able to extract relevant information; strong organizational/administrative skills a must. Knowledge of insurance plans, authorization processes, and medical terminology; strong problem-solving and critical-thinking skills. Traits: Organized, high-integrity, attention to detail, dependable, quality focus, empathetic, strong listener/communicator, proactive, and patient-focused Other: Energetic, highly motivated, adaptable, and team-oriented with strong personal and communication skills; strong customer service skills; discretion and confidentiality essential as position deals with highly sensitive and private data Experience & Requirements • High school diploma or GED required, • Current certification and/or licensure as a Pharmacy Technician in the state where the site is located is required (North Carolina). Should additional licensure need to be obtained, the applicant will commit to obtaining the required licensure within a mutually agreed upon timeframe. Continued employment is contingent upon meeting these requirements., • PTCB or NHA certification preferred. If the candidate does not have the PTCB or NHA at time of hire, they must commit to obtaining it within 9 months of employment., • 5+ years health care experience required; 3+ experience as a pharmacy technician required, • 3+ years' experience with infusions, coordinating and subcontracting referrals, infusion and medical reimbursement required; experience must include medical pre-certification, benefits investigation, prior authorization, and financial assistance strongly preferred, • Experience with infusion, specialty pharmacy, and/or home infusion workflows strongly preferred, • Understands the pre-certification process for specialty/non-specialty infusions; knowledge and understanding of nuances of infusion therapy v. "standard" outpatient specialty pharmacy, • Experience with major and local medical plans preferred; strong knowledge of Medicare and Medicaid regulations and commercial insurer criteria for payment of infusion and home care services, • Understanding of medical vs. pharmacy benefit distinctions, site‑of‑care policies, white‑bagging/brown‑bagging requirements, and authorization processes, • Familiarity with J‑codes, HCPCS codes (including per diem and nursing), and common infused medications highly beneficial, • Highly proficient in systems such as MS Office (e.g., Word, Excel), EMR systems (e.g., EPIC, Cerner), and dispensing systems (e.g. CPR+, EPIC WAM), • Strong interpersonal skills, strong verbal and written communication skills, • Strong mathematical skills, including calculating doses, out of pocket costs based on benefits, • Strong time management skills, • Strong communication, critical thinking, and clinical documentation review skills; ability to make fast, accurate routing decisions based on payer rules, clinical factors, and operational constraints California residents employed by or applying for work at Shields have certain privacy rights. Please review our: California Workforce Privacy Notice and Privacy Policy. By providing your mobile number, you agree to receive text messages from Shields Health Solutions related to job opportunities, interview scheduling, and recruiting updates. Message and data rates may apply. You may opt out at any time by replying 'STOP.' Consent is not a condition of employment. Shields Health Solutions provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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