Key Responsibilities:

Buy and Bill Drug Oversight

• Oversee enrollment and active management of patients on biologics drugs to ensure continuity of therapy and identification of conversion opportunities.
• Monitor eligibility changes, formulary updates, and payer policy shifts for these drugs that may open new buy and bill conversion pathways.
• Collaborate with the clinical team on therapeutic alternatives when these drugs face barriers to coverage.

Prior Authorization & Benefits

• Manage and monitor PA renewals for these patients, whether on specialty pharmacy or buy and bill, to ensure timely authorization and minimize gaps in therapy.
• Lead benefits investigation for conversion candidates, including payer-specific buy and bill coverage analysis and appeal strategy.
• Identify and escalate missed PA renewal cases and delegate corrective actions to team members.

Revenue Cycle & Financial Oversight

• Partner with RCM to monitor claims for buy and bill injections, ensuring accurate billing and expected reimbursement levels.
• Review monthly reporting packages, including new buy and bill starts, active buy and bill patient counts, buy and bill conversion metrics, and reconciliation sign-off.
• Identify revenue risk from leakage of these drugs to specialty pharmacy dispensing and develop action plans to address with clinic and pharmacy teams.

Buy and Bill Stewardship & Conversion

• Identify all active patients on buy and bill eligible drugs and manage proactively to maintain in-office administration.
• Conduct systematic review of these patients at renewal to assess buy and bill conversion eligibility and initiate PA and benefits work accordingly.
• Pursue buy and bill alternative pathways at the time of drug denial, working with benefits and PA teams to identify formulary substitutes.
• Coordinate with pharmacy partners and patients to facilitate smooth transitions from specialty pharmacy dispensing to in-office buy and bill.
• Maintain and report on a conversion pipeline, tracking patients by status (candidate, in-process, converted, ineligible).
• Review and verify patient schedules to ensure appropriate drug ordering based on scheduled patient

IG Patient Management

• Oversight and steward IVIG/SCIG patients, maintaining coordination with pharmacy and patient contacts.
• Track patient concentration by location to inform long-term infusion clinic planning and resource allocation.
• Serve as the primary liaison for IG-related coordination issues across clinics, pharmacy, and patient stakeholders.

• Strong understanding of buy and bill reimbursement models and specialty pharmacy operations
• Experience with prior authorization processes and benefits investigation, including payer-specific buy and bill coverage analysis
• Understanding of Revenue Cycle Management and Biologics Billing
• Excellent organizational and project management skills with the ability to manage a regional patient population
• Strong communication skills, both verbal and written
• Creative problem-solving and sound decision-making ability
• Strategic and analytical mindset with keen attention to detail
• Excellent relationship management skills; ability to work collaboratively with internal and external teams
• Ability to lead, train, and motivate a team
• Accountability, adaptability, and discretion
• Ability to travel across assigned region
• Clinical background (clinician preferred)
• PACS certification or at least two years of prior authorization experience
• Experience with specialty biologics, IVIG/SCIG, or infusion therapy management
• Familiarity with Lux Infusion or similar specialty pharmacy coordination platforms
• Ability to analyze data and reports to drive operational decisions

• Ability to sit for extended periods and communicate effectively, including speaking and hearing
• Ability to perform repetitive tasks such as typing
• Information processing, memory recall and ability to exercise independent judgment