Claims Analyst Pharmacy Revenue Cycle

Duration: 3 months to start

About the Role

Revenue cycle management (RCM) is the financial process that enables healthcare organizations to fulfill their mission of providing quality care for patients and communities. Pharmacy revenue cycle is a complex process requiring a collaborative and specialized approach. Improving performance involves fine-tuned workflows, training, dedicated resources, collaboration across multiple departments, and routine updates to core systems.

Under the direction of the Revenue Cycle Supervisor Pharmacy, the Revenue Cycle Claims Analyst is responsible for pursuing insurance companies for payment or underpayment of services rendered through extensive telephone and written correspondence. The role involves substantiating accurate reimbursement through correct contract terms, billing practices, and compliance with state and federal guidelines. Analytical, auditing, problem-solving, and reconciliation skills are critical. Conducts duties in accordance with industry federal and state billing guidelines, contractual obligations, and department policies and procedures.

As part of the Pharmacy Complex Claims team, this role brings traditional revenue cycle functions into the department of pharmacy, providing significant opportunities for the health system by identifying and recovering overlooked revenue through financial, pharmacy, and medical revenue cycle expertise.

Responsibilities

• Research, resolve, and prepare claims that have not passed the payer edits daily.
• Determine and initiate action to resolve rejected drug claims.
• Serve as subject matter expert for strategic provider relationships, service issues, reimbursement, and claims.
• Possess excellent medical and billing terminology skills; ability to read, analyze, and interpret prescription drug orders.
• Monitor rejections on all electronic and paper claims to determine where enhancements or fixes are needed in system edits to gain efficiencies and prevent ongoing rejections.
• Apply knowledge of Medicare and third-party codes, billing procedures, and patient billing techniques.
• Effectively communicate issues and results via multiple media, including in-person meetings, workgroups, verbal communication, email, and presentations.
• Assess billing for accuracy prior to submission using knowledge of Medicare and other regulatory billing codes and practices.
• Collaborate with team and other revenue cycle departments to improve denials and avoidable write-offs.
• Apply analytical skills to pre-established work processes, including preparation of reports or documents for further review or analysis.
• Research, analyze, and respond to inquiries regarding compliance, payor policies and guidelines, inappropriate coding, denials, and billable services.
• Follow up on outstanding account balances at 45-days from the date of service in accordance with organizational protocol, emphasizing client satisfaction and provider profitability.
• Utilize the Hospital's Core Values as the basis for decision-making and to facilitate the hospital mission.
• Monitor and resolve Claims Work queues, specifically Front End, Referrals & Authorizations, and Clinical Workflow.
• Convert pharmacy drug quantities into Medicare billing units according to Medicare Guidelines prior to submitting medical CMS1500 claim forms.
• Ensure all billable services are processed in EPIC in a timely manner.
• Serve as a Subject Matter Expert (SME) for complex denials and payment variances, including contracts, fee schedules, and edits.
• Educate and provide feedback to various areas on Pharmacy Revenue Cycle rejection metrics and key performance indicators.

Requirements

• Bachelor’s degree in Business, Healthcare, or a closely related field, or equivalent work experience.
• 1 to 3 years of experience in healthcare, coding, finance, revenue cycle, patient accounting, and/or physician billing, preferably in a Medical Center setting, Oncology, or Home/Office Infusion settings.

Qualifications

• Certified Pharmacy Technician (Preferred).
• Coding Certification (CPC, RHIT) (Preferred).
• Advanced working knowledge of professional billing flows, including charge entry, editing system functionality, and revenue cycle tasks.
• Ability to analyze and solve complex problems related to system processes and workflows.
• Strong knowledge of claim edits (NCCI - National Correct Coding Initiative Edits and MUE - Mutually Unlikely Edits).
• Superior analytical skills to critically evaluate information gathered from multiple sources and synthesize it into actionable information.
• Strong interpersonal skills to elicit cooperation from a wide variety of sources, including upper management, clients, and other departments.
• Ability to organize, interpret, and present data with attention to detail.
• Effective communication skills in both written and oral forms, tailoring messages to the audience.
• Understanding of the business, products, programs, corporate organizational structure, and basic research principles/methodologies.
• Working knowledge of CPT/HCPCS and ICD-10-CM-PCS diagnosis codes, including understanding current professional coder workflows and reviewing principal, secondary diagnoses, and procedures for hospital and physician services.
• Knowledge of hospital and professional billing, collection and reimbursement requirements, and standard practices.
• Working knowledge of drug NDC numbers and unit conversion.