Pharmacy Revenue Analytics Program Lead - Silver Spring, MD

Revenue Optimization Program Administration

Develop policies, guidelines, and procedures for pharmaceutical coding, billing, pricing, charging, and denial management to maximize reimbursement and compliant charging.

Perform quality reviews in order to ensure that the pharmacy charge description master (PCDM) additions, inactivations, changes and/or revisions were accurately completed in the hospitals clinical and financial systems.

Work with Pharmacy & Therapeutics Committees, Oncology Service Lines, and Managed Care to ensure formularies are aligned.

Actively research and stay current with important billing and revenue-related compliance and optimization topics to guide appropriate organizational decisions.

• Collaborate with Finance, Revenue Integrity, Compliance, Decision Support, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue, business processes, billing, denial management, and collections.
• Lead pharmacy charging or revenue related projects and workflow changes, document areas of risk, financial impact and workflow procedures.
• Communicate findings to management and overseeing the implementation of approved recommendations to ensure appropriate revenue capture.
• Develop process flows, education, and communications to improve revenue integrity and compliance.
• Collaborate with upper management to evaluate current as well as new program initiatives for effectiveness, feasibility, performance measurement, and cost; ensure compliance with organizational and departmental policies and procedures, and regulatory standards.
• Participate and lead committees, work groups, process improvement efforts, and educational initiatives to improve pharmacy revenue integrity and the pharmacy billing cycle.
• Act as the system expert on medication-related compliance billing and charging topics.
• Provide education to site and system stakeholders to drive optimal revenue capture.
• Work with sites, managed care, and the business office to decrease medication-related claim denials and outstanding claims.
• Serve as a liaison between Finance, Revenue Integrity, Compliance, Decision Support, Pharmacy, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue, business processes, billing, denial management, and collections.
• Collaborate with Pharmacy Leadership to determine patient access to high cost injectable therapies and other related reimbursement options, provide assistance on 340B operational reporting as it pertains to hospital outpatient departments.

Program Reporting, Analytics, & Information Resources Management

Responsible for overall Pharmacy Revenue Cycle Dashboard reporting on both a weekly and monthly basis, which includes data mining and report interpretation to ensure key themes are identified, addressed, and appropriately escalated.

Develop analytical tools to audit and analyze hospital pharmacy data elements to ensure accurate billing and maximal revenue capture.

Analyze data on all Pharmacy Revenue KPIs.

• Maintain monitoring, tracking, and trending of special scenarios impacting revenue, such as oncology patients, temporary patients, medication waste, interdepartment chargebacks, etc.
• Participate in the financial analyses of any proposed changes to determine charge and revenue implications related to the PCDM maintenance.
• Develop quality metrics and audit methodologies to drive accuracy and first-time quality for all HCPCS/CPT codes, revenue codes, billable units, multipliers, modifiers, indications, etc.
• Provide strategic support of AR Strategy as it relates to items such as reporting and identify focus areas for improvement.
• Routinely identify enhancements to reports and/or tools to support leading practice processes and facilitate continuing Pharmacy Revenue Cycle improvement; provide content expertise in the development, implementation, revision and management of data systems that support the Pharmacy Revenue Cycle.
• Identify revenue improvement opportunities through analysis of data and review of current processes.
• Ensure ad hoc report requests received from other departments in the organization are managed timely and accurately.
• Provide recommendations to reporting teams for optimal pharmacy workload statistics and other pharmacy reports or dashboards.
• Acts as the “super user” of the Pharmacy Revenue Cycle and other reporting tools; provide key input and participation on any system upgrade or enhancement affecting these systems.
• Utilize multiple IT systems to manage analysis, issue research and resolution, and process improvement implementation, including but not limited to: Business Objects, Avalead, etc.
• Perform analysis and data mining of charge, payment, and denials information using analytical tools (Excel, Access) and available reporting; oversee data analysis, trending and management reporting related to Pharmacy Revenue Cycle.
• Acknowledge and support initiatives related to Pharmacy Revenue Cycle systems optimization and ensure organizational preparedness and compliance.