Pharmacy Business Coordinator - Home Infusion (Billing and Revenue Cycle)

About the role

This position is responsible for conducting payer discussions, in-house financial audits, payer performance compliance, prepayment claims audit, CMS CERT audits, CMS Fraud, Waste, & Abuse audits, and auditing 3rd party payer compliance. They must maintain knowledge of revenue cycle operations, third party reimbursement procedures & regulations, payer relations, claims adjudication, contractual claims processing, medical terminology, and an understanding of the 340B Drug Discount Program.

Responsibilities

• Drafts various correspondence letters and sends to referral source when necessary.
• Gathers and documents demographics, insurance information, needs assessment, and other data as needed.
• Provides information and answers to patient/caregiver questions and refers to clinician when appropriate or requested.
• Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.
• Enters pre-registration using the comprehensive data elements into the registration/billing.
• Contacts insurance company or employer to determine eligibility and benefits for requested services.
• Performs medical necessity screening as required by third party payers.
• Identifies managed care admission/treatment requirements and assures the requirements are met to guarantee payment of the account.
• Initiates charge anticipation calculations.
• Accurately identifies anticipated charges to assure identification of anticipated self-pay portions.
• Communicates with the patient the anticipated self-pay portion (co-payments/deductibles/co-insurance) and establishes payment arrangements based on the Financial Policy and documents the financial resolution in the registration/billing systems.
• Maintains current knowledge of major payor payment provisions and regulations.
• Maintains registration accuracy threshold of 98% as identified in audit processing.
• Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.
• Attends departmental meetings and/ or documents review of meeting minutes.
• Participates in quality activities as assigned by Specialty Pharmacist Manager.
• Participates in performance improvement (i.e. follows established work systems, identifies deviations or deficiencies in standards/systems/processes and communicates problems to coordinator or manager).
• Maintains confidentiality according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.
• Communicates problems hindering workflow to management in a timely manner.
• Demonstrates the knowledge and skills necessary to communicate to the infant, pediatric, adolescent, adult and/or geriatric patient per the established age-specific education/standard.
• Assesses all self-pay patients for potential public assistance through registration/billing systems.
• Obtains commitment to pay from patients that do not meet requirements for public assistance or full charity write off.
• Maintains database that lists all pharmacy contracts that are currently on file. (both Retail and Specialty)
• Performs routine contract reconciliation at prescription level detail.
• Reviews all pharmacy payer (Commercial & Government) contract terms, identify and report areas of concern or changes in contracts that could have a negative impact on the organization.
• Responsible for periodically reviewing pharmacy contracts (at least annually) for updates or changes in contract language as well as seeking higher reimbursement rates.
• Facilitates discussions with insurance companies to resolve payment issues and to identify payment, overpayments, and underpayments.
• Conducts claims extracts and payer payment evaluations to perform contract compliance tests.
• Organizes meeting materials and attends various organization meetings as needed.
• Manages customer service related phone calls or written requests related to pharmacy contracting issues and ensure timely resolution.
• Comprehensive understanding of the 340B Drug Discount program in addition to assisting with compliance of the 340B Drug Discount Program.

Requirements

Minimum Qualifications:

• Bachelor’s Degree in healthcare administration, business, finance, or related field AND one (1) year of business OR healthcare-related experience OR
• High School Diploma or Equivalent AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND two (2) years of healthcare-related experience OR
• Associate’s Degree AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND one (1) year of healthcare-related experience

Preferred Qualifications:

• Patient and professional demeanor.
• Knowledge of drugs, drugs dosing, side effects, indications, contraindications and proper administration preferred.
• Knowledge of rules, policies and regulations related to the disbursal of pharmaceutical drugs preferred.
• Knowledge of clinical procedures or operations.

Qualifications

• Education: Bachelor’s Degree in healthcare administration, business, finance, or related field OR High School Diploma or Equivalent AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND two (2) years of healthcare-related experience OR Associate’s Degree AND Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND one (1) year of healthcare-related experience.
• Experience: One (1) year of business OR healthcare-related experience OR two (2) years of healthcare-related experience OR one (1) year of healthcare-related experience.
• Certification/License: Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire.

Skills and Abilities

• Uses computers and software applications.
• Knowledge of drugs, drugs dosing, side effects, indications, contraindications and proper administration preferred.
• Knowledge of rules, policies and regulations related to the disbursal of pharmaceutical drugs preferred.
• Knowledge of clinical procedures or operations.
• Ability to communicate effectively verbally and in writing.
• Ability to work with multiple demands.
• Ability to work accurately, efficiently, and safely in a fast-paced environment.
• Ability to communicate effectively with staff, physicians, patients and families.
• Flexibility to meet the needs of department or hospital in regard to changes in work volume, planned change, scheduling changes and emergency call-backs (i.e. weather or disaster).

Physical Requirements

• Prolonged sitting.

Working Environment

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.