340B Eligibility SpecialistPosition Summary
The 340B Eligibility Specialist is responsible for ensuring compliance with the federal 340B Drug Pricing Program by verifying patient, provider, and prescription eligibility, monitoring program integrity, and supporting covered entities with day-to-day 340B operations. This role works closely with pharmacy, clinical, billing, compliance, and third-party administrators (TPAs) to maximize program savings while maintaining strict compliance with HRSA regulations and manufacturer requirements.
Essential Duties and ResponsibilitiesProgram Eligibility & Compliance
- Verify patient eligibility for 340B-qualified prescriptions.
- Ensure prescriptions meet HRSA patient definition requirements.
- Review provider eligibility and maintain eligible prescriber lists.
- Validate encounter documentation supporting 340B eligibility.
- Monitor compliance with HRSA regulations, OPA guidance, and manufacturer requirements.
- Assist with internal audits and HRSA audit preparation.
- Identify and investigate potential diversion or duplicate discount concerns.
Claims & Data Management
- Review prescription claims for eligibility and accuracy.
- Research exceptions, claim rejections, and split-billing discrepancies.
- Monitor TPA submissions and investigate missing or delayed claims.
- Validate data feeds between EMR, pharmacy dispensing systems, wholesalers, and TPAs.
- Assist with correction and resubmission of claims when necessary.
Manufacturer & Contract Pharmacy Support
- Monitor manufacturer-specific policies, ESP requirements, and data submission processes.
- Coordinate with contract pharmacies regarding eligibility questions and claim reconciliation.
- Assist with manufacturer inquiries related to replenishment or claim validation.
- Track reimbursement trends and investigate replenishment issues.
Reporting & Analytics
- Generate routine eligibility and compliance reports.
- Monitor financial performance related to 340B savings.
- Identify trends affecting program performance.
- Assist leadership with reporting for audits and executive review.
Education & Collaboration
- Educate clinic staff regarding patient eligibility requirements.
- Participate in onboarding of new clinics, pharmacies, and providers.
- Collaborate with pharmacy, finance, IT, compliance, and clinical operations.
- Serve as a resource for eligibility and operational questions.
Required Qualifications
- Associate's or Bachelor's degree in Healthcare Administration, Pharmacy, Nursing, Business, or related field preferred.
- Minimum 2 years of healthcare experience.
- Experience with the 340B Drug Pricing Program strongly preferred.
- Knowledge of pharmacy claims processing.
- Experience working with electronic medical records (EMRs).
- Proficiency in Microsoft Excel and Microsoft Office.
Preferred Qualifications
- 3–5 years of 340B program experience.
- Experience with split-billing software (Verity, Macro Helix, Sentry, Wellpartner, etc.).
- Experience working with contract pharmacies.
- Familiarity with ESP and manufacturer restrictions.
- Knowledge of Medicaid billing and duplicate discount prevention.
Knowledge, Skills & Abilities
- Strong understanding of 340B regulations and HRSA guidance.
- Excellent analytical and problem-solving skills.
- Ability to interpret pharmacy claims and clinical documentation.
- Strong attention to detail.
- Excellent written and verbal communication skills.
- Ability to prioritize multiple projects in a fast-paced environment.
- Strong customer service and relationship management skills.
- High level of integrity and confidentiality.
Physical Requirements
- Prolonged periods of sitting and computer work.
- Ability to occasionally lift up to 20 pounds.
- Ability to travel occasionally for training or client support, if required.
Key Performance Indicators (KPIs)
- Percentage of eligible claims accurately identified.
- Reduction in non-qualified or diverted claims.
- Timeliness of claim review and issue resolution.
- Audit readiness and compliance scores.
- Accuracy of provider eligibility maintenance.
- Resolution time for eligibility investigations.
- Client satisfaction and responsiveness.
- Financial optimization through accurate 340B capture.
Pay: $50,000.00 - $60,000.00 per year
Benefits:
- Health insurance
- Paid time off
Work Location: In person
