Independent Health

Pharmacist

• Prepare and dispense medications, including sterile admixtures and non-admixtures, equipment, and supplies
• Evaluate physician-ordered medications for appropriateness of therapy and maintain patient-specific optimal therapy
• Prepare patient records and maintain medication profiles
• Perform care planning, drug interaction evaluation, clinical monitoring, pharmacokinetic monitoring, renal dosing, and laboratory and culture monitoring
• Determine medication administration compliance and effectiveness and conduct discharge planning
• Provide drug information, clinical consultation, and patient counseling
• Communicate with physicians, nurses, and patients
• Order and manage medications, controlled substances, equipment, and supplies
• Provide and coordinate pharmaceutical services and pharmaceutical care activities
• Monitor, evaluate, document, and report patient outcomes
• Coordinate clinical pharmacy care for assigned patient populations
• Perform patient assessments, progress/communication notes, clinical case conferences, ongoing clinical assessments, and discharge summaries
• Ensure adherence to laws, regulations, company policies, and URAC and ACHC standards
• Participate in Quality Assurance and Performance Improvement activities
• Prepare or supervise preparation of sterile admixtures and non-admixtures
• Assist with procurement and management of medications, controlled substances, equipment, and supplies
• Maintain professional working relationships and coordinate clinical team activity
• Interact with other departments, attend meetings, and conduct presentations
• Maintain pharmacy coverage and assist personnel in completing workload

Learning and Development

• Design, develop, deliver, implement and refine training for new and existing associates
• Support training needs for organizational initiatives and corporate strategic priorities
• Develop, deliver and grade skill assessments
• Schedule and communicate new hire training
• Communicate trainee performance
• Create and update trainee handbooks and manuals
• Deliver individual, small-group and large-forum training
• Supervise new hire classes, including disciplinary functions and timecards
• Develop and deliver staff development training and continuous associate improvement programs
• Coordinate with resource coordinators to identify staff development improvements
• Assist with training on new products, benefits changes, system updates and other information
• Maintain department portal pages
• Research information, staff needs, training coordination and student performance with various departments
• Coordinate training and onboarding with Human Resources
• Work with quality assurance and resource management to ensure training is appropriately developed and delivered
• Coordinate new hire orientations
• Provide ideas on system updates requiring specific testing
• Research policies, procedures, contracts and benefits with other functional areas

Training Specialist – Operations

Project Manager

• Develop strategic initiatives and organizational project plans through completion
• Consult with teams to maintain project objectives and clarify processes
• Communicate team decisions, project barriers, and project status to senior management or appropriate authority
• Coordinate and facilitate project activities using PMI best-practice tools and processes
• Manage project scope and ensure business objectives are met
• Support a corporate approach to project management
• Lead project teams from initiation through implementation
• Develop and maintain scope documents, project timelines, work breakdown structures, budgets, and resource requirements
• Manage enterprise project dependencies
• Identify and manage risks, issues, and key decisions; develop contingency plans and escalate issues
• Address roadblocks, negotiate for resources, and resolve problems with senior leadership
• Assess organizational project impact and prepare status reports with recommendations
• Identify, propose, and implement workflows and processes to support operational and strategic initiatives
• Assist with development and selection of project management tools and maintain appropriate documentation
• Maintain current project management knowledge and incorporate new tools and methodologies
• Provide updates to leadership, Senior Leadership Team, and enterprise governance bodies
• Ensure proper resource allocation and escalate resource constraints
• Lead project closure and conduct post-implementation evaluations
• Provide team leadership, facilitation, and direction
• Support corporate strategic priorities
• Manage projects from initiation through delivery while defining and documenting business needs
• Elicit, analyze, and document business requirements
• Translate business needs into functional specifications or user stories
• Support solution design and validate requirements
• Conduct gap analyses and propose process improvements

Business Project Manager

Nurse

• Provide care management services to applicable pharmacy, medical, and home care patients
• Collaborate with operations and pharmacy staff to ensure appropriate billing and reimbursement
• Assist with care plan reviews, adherence calls, therapy goal assessments, patient management program assessments, and device training
• Communicate with patients, providers, and health care team members to ensure optimal patient care and improved outcomes
• Perform digital patient contact through the Reliance Rx patient management program to assess medication efficacy, compliance, and related patient-care factors
• Adhere to applicable regulations, patient care standards, and NYS DOH-approved policies and procedures
• Assess patients’ immediate and long-term needs using social and medical history and vitals
• Develop plans of care with providers and patients within scope of practice
• Provide disease-state education, medication administration training, medication-compliance outreach, and clinical interventions
• Complete training related to administering IV and SQ biologics
• Complete required continuing education and clinical training
• Train patients on medical devices
• Monitor billing and reimbursement for drugs, supplies, and time
• Safely administer medications according to prescribed dose, frequency, and intended use
• Obtain and maintain necessary certifications
• Assess and document member response to care plans and revise plans as needed
• Perform and document initial and follow-up RELI-Rx assessments
• Review and assess therapy goals and other clinical touchpoints
• Ensure compliance with local, state, and federal laws and employer policies, including privacy and confidentiality requirements
• Participate in project teams and medical management initiatives
• Collaborate with Independent Health Case Management on needs and future opportunities
• Maintain transportation and travel-related expenses
• Assist with associate orientation as needed

Registered Nurse

Credentialing Specialist

• Maintain timely and accurate credentialing and re-credentialing of all Independent Health providers
• Manage provider files and documentation in adherence with regulatory requirements and Independent Health policies
• Work with internal departments to ensure provider data accuracy
• Provide effective, professional external customer service
• Maintain all work through the Healthrules system
• Input provider applications into the credentialing database and process within required time frames
• Ensure applications are complete, accurate, and compliant with NCQA, DOH, CMS, and Independent Health policy requirements
• Complete and close clean, routine applications and assigned recredential files within required time frames
• Initiate credentialing packets as assigned and scheduled
• Track processes to maintain compliance with federal, state, NCQA, and internal requirements
• Follow up and take action on conflicting or incomplete information
• Review and edit files for completeness and accuracy before analyst review
• Maintain Network Evaluation process and physician network profiles
• Gather and document information from respective departments for recredentialing review
• Perform primary source verification using credentialing software according to IPA/WNY policies and procedures
• Query primary sources by letter or phone to verify information
• Initiate additional requests when responses are not received within required time frames
• Query databases and internet sources to verify licenses, board information, sanctions, and claims history
• Maintain the credentialing database and provider hard-copy files
• Enter changes and update provider credentialing database records in Cactus and Health Rules
• Remain current and informed on credentialing policies and procedures
• Generate routine and follow-up reports from the system
• Provide the manager with month-end status reports of assigned files

Analyst

• Integrate claims, membership, provider, risk score, EMR, ADT, and other data sources
• Develop reports and complex analyses to understand and explain quality measure trends and their drivers
• Collaborate with business units to identify opportunities to close quality gaps in care
• Forecast quality measure trends
• Work with the Quality Workgroup team on initiatives to improve quality measure rates
• Support annual HEDIS and QARR data submissions
• Help respond to HEDIS auditor concerns
• Develop standard reports using SAS, SQL, Quality Reporter, or other reporting tools
• Model quality measure rates to quantify gap-closure opportunities and identify intervention-receptive measures
• Develop custom quality measures for regulatory performance-improvement reporting
• Work cross-functionally to ensure measure reporting is transparent to providers
• Handle multiple complex analyses in response to day-to-day requests
• Develop reports, charts, visualizations, and analyses explaining quality measure trends
• Present outputs in a user-friendly manner
• Provide results summaries and recommendations
• Review and validate data and findings before releasing reports to QA analysts and customers
• Deliver work according to department SOP
• Research topics and develop ideas supporting department or corporate strategic goals
• Assist with implementing new capabilities, vendor software, applications, and data sources
• Stay current on research and apply new techniques

Quality Measurement & Improvement Analyst – Intermediate

General

• Adjudicate and adjust medical and/or dental claims against established criteria and specific client SPDs
• Respond to client, member, and provider inquiries about claim status, benefit designs, and claim payments in conjunction with Customer Service Representatives
• Adjudicate facility, professional, member-submitted, pharmacy, and dental claim edits for in-network and out-of-network benefits
• Review vouchers and explanations of payments to identify and resolve claims-related issues
• Meet department performance measures for production, accuracy, policy and procedure knowledge, and timeliness
• Analyze, identify, and research policy, payment, and coding issues
• Maintain current contract, summary plan description, and benefit knowledge
• Adhere to departmental deadlines, turnaround times, and state and federal regulations
• Use critical thinking to process claims
• Navigate systems and applications to locate claim-specific information
• Locate, interpret, and apply appropriate resources to claim scenarios
• Identify and communicate process improvement opportunities
• Prioritize and manage claim-processing workload efficiently
• Collaborate with other Independent Health departments to resolve claims payment problems

Claims Adjudicator

Representative

• Act as a customer advocate by answering phone calls, written correspondence and servicing walk-in members in a timely fashion
• De-escalate customers and resolve customer complaints
• Provide accurate and up-to-date information on policies and procedures and communicate successful resolutions
• Ensure compliance with all CMS rules and regulations
• Log all contacts into appropriate systems
• Meet or exceed quality, productivity and accuracy goals measured by the representative’s scorecard
• Maintain technical knowledge regarding Pharmacy Benefit Dimensions’ contracts, benefits, policies and procedures
• Attend required training sessions as needed
• Document pertinent information into appropriate systems to meet NCQA, state and CMS standards
• Address first-level complaints and provide assistance on appeals as needed
• Resolve written inquiries regarding claims, benefits, eligibility, reimbursement and participating providers
• Coordinate the use of multiple systems and training manuals simultaneously
• Perform other duties as required, including walk-in member servicing, correspondence support and outbound calls

Servicing Representative

Advocate

• Organize and collect information from patients during follow-up telephone contacts
• Track and report individual and aggregate clinical information
• Apply positive communication skills with internal and external customers
• Deliver cost-effective, high-quality care
• Facilitate a systematic approach to surveillance and educational outreach
• Assemble and review clinical records from physician offices, patients, and internal data systems
• Forward patients outside the defined acceptable range to a Pharmacist for case review
• Use pharmacist-defined assessments to screen for potential issues and report issues to a pharmacist
• Contact patients to obtain accurate and timely information, facilitate positive outcomes, and determine therapy tolerance
• Document and report adverse events, adverse effects, and lack of tolerability to physicians, pharmacy, and management
• Use CPR+, MS Office, Word, Excel, and PowerPoint to record data and create reports
• Assist with maintenance of Prior Authorization forms
• Maintain positive communication and resolve difficult situations
• Follow applicable pharmacy and nursing laws and established procedures

Adherence Advocate

• Assist in pharmacy department activities under the supervision of a licensed pharmacist
• Assist with fulfillment for infusion patients
• Replenish and maintain pharmaceuticals, equipment, and medical supplies
• Maintain patient records, including infusion orders
• Assist in appointment coordination for infusion patients when necessary
• Set up, package, and label medication doses
• Process equipment and supply orders
• Package and ship specialty prescriptions, infusion orders, product returns, and equipment for maintenance
• Maintain infusion pump maintenance logs and coordinate replacement and maintenance
• Coordinate stock infusion supplies with nursing support based on patient need
• Assist Pharmacy Buyer with inventory processes and organization
• Assist in replenishment of incoming specialty pharmacy stock
• Assist in physical inventory
• Maintain knowledge of pharmaceutical safety hazards and drug handling
• Ensure separation of duties for purchase, replenishment, inventory, and payment
• Notify pharmacists of dispensing, storage, packaging, and related issues
• Rotate stock, supplies, packaging materials, and shipping supplies
• Maintain cleanliness of registered and packaging spaces
• Follow standard written procedures and guidelines, with deviations approved by the supervising pharmacist

Pharmacy Technician – Infusion and Replenishment

Patient Care

• Answer patient inquiries about billing, procedures, policies, and available services through incoming and outgoing calls
• Act as a liaison between patients and insurance companies
• Facilitate communication between patients, doctors, medical staff, and administrative staff
• Maintain patient records, filing, and documentation
• Perform set-up and data entry
• Package and ship orders
• Arrange finances and collect co-payments
• Coordinate benefits
• Coordinate financial assistance
• Assist offices with prior authorizations
• Perform billing
• Work as a team member within the patient services department and other departments to promote information sharing and continuous process improvement
• Function in strict accordance with standard written procedures and guidelines, with deviations approved by the supervising pharmacist

Patient Care Specialist

Manager

• Apply the six essential case management activities: assessment, planning, implementation, coordination, monitoring and evaluation
• Assess patients’ immediate and long-term social and medical needs
• Develop and update patient-centered plans of care considering physical, psychosocial, benefit plan and cost-benefit factors
• Monitor care quality, effectiveness and changing patient needs
• Ensure regulatory, privacy, payment/reimbursement and appeal-process compliance
• Coordinate decisions, documentation and maintain an accurate database
• Establish relationships with interdisciplinary teams and communicate case objectives
• Advocate for patients and identify potential complications
• Apply the Americans with Disabilities Act and relevant federal legislation
• Research community resources and help patients obtain applicable services
• Identify and implement alternative care levels and resources, including rehabilitation and home health care
• Evaluate quality and cost effectiveness with payors, providers and team members; negotiate discounts when appropriate
• Apply case management, problem-solving, confidentiality and liability concepts
• Document plans of care timely and analyze outcomes
• Participate in professional organizations, continuing education, Nova training and education committees
• Support staff orientation, training and provide guidance to support staff
• Perform assignments professionally and practice within the scope of multi-state licensure

Case Manager

• Facilitate logging in and out of prior authorization, appeal, reimbursement and grievance requests
• Follow up on requests to ensure timely resolution and completion
• Ensure process steps and regulatory requirements are completed
• Address provider questions regarding formularies through the pharmacy medical exception line
• Provide administrative support including faxing requests, completing decision letters, making notification calls, filing and document scanning preparation
• Verify member and provider eligibility and file requests into correct member folders
• Enter prior authorization request data and maintain accurate statistics in pharmacy systems
• Enter overrides and update required documentation systems; transcribe Medical Director decisions when needed
• Complete reports, reimbursement requests, IRO reviews and vendor email/report reviews
• Make follow-up and outbound calls to members, providers and physicians regarding approvals, denials and decisions
• Resolve provider and internal caller questions regarding formulary and prior authorization
• Research and respond to escalated and complex pharmacy inquiries
• Provide required letters within required timeframes
• Fax, copy, mail and prepare completed requests for scanning
• Maintain file storage according to corporate retention policy

Prior Authorization Coordinator

• Oversee and manage client, vendor, and other business contracts and agreements
• Capture, define, and understand PBD business needs and ensure those needs are represented in contracts and agreements
• Draft, review, negotiate, and facilitate execution of contracts and agreements
• Liaise between PBD business units, Independent Health legal department, outside legal counsel, and vendors
• Conduct state and federal regulatory research and monitoring
• Prepare, file, and manage business registrations and licenses
• Research and monitor PBM regulations and business requirements
• Complete and facilitate initial and renewal license and registration applications
• Develop and maintain compliance tracking and monitoring processes
• Facilitate and oversee contracting processes for RFPs, ASAs, amendments, vendor agreements, rebate contracts, pharmacy and network contracts, and software licenses
• Maintain contract-term tracking, performance metrics, policies, procedures, and documentation
• Communicate needs, status, and performance metrics to key stakeholders

PBM Contract Manager

• Analyze utilization, claims, membership, and cost data in support of the Network Contract Management department and corporate strategic initiatives
• Design and use analytical tools to draw statistically sound conclusions and present results to management
• Interpret, analyze, and recommend courses of action concerning fair, equitable, and market-competitive reimbursement
• Design and conduct analyses for provider contract negotiations, alternative reimbursement models, high-quality/high-value care, policy changes, government mandates, consolidations, and provider-community mergers
• Independently design and conduct analyses by developing assumptions and constraints, interpreting results, drawing conclusions, and developing feasible alternatives
• Present analytics results and recommendations to management regarding reimbursement and pricing
• Create analytical tools supporting strategic initiatives and reimbursement and pricing decisions
• Apply reimbursement methodologies and coding requirements such as DRG, CPT, and diagnosis codes across provider networks and services
• Analyze provider networks, patterns and profiles, medical cost and utilization trends and drivers, and reimbursement and fee change models
• Advise management on reimbursement and regulatory changes affecting financial performance
• Participate in or lead analytics and research on alternative reimbursement initiatives and assess impacts on policies and procedures
• Document procedures, steps, results, and findings
• Validate data and ensure report/information accuracy through quality assurance and balancing procedures
• Participate in or lead corporate initiatives involving data warehousing, data integrity, new administrative platforms, and treatment cost estimators
• Collaborate with analysts and other departments