Claims Analyst - Pharmacy Revenue Cycle

POSITION SUMMARY:

Revenue cycle management (RCM) is the financial process that makes it possible for healthcare organization to fulfil their mission of providing quality care for patients and communities.  Pharmacy revenue cycle is complex process and requires a collaborative and specialized approach. Improving performance requires 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 through extensive telephone and written correspondence, will pursue insurance companies for payment or underpayment of services rendered. Will also substantiate accurate reimbursement through correct contract terms, billing practices and compliance with state and federal guidelines.  Must have the ability to analyze, audit, problem solve and reconcile an account is critical to this position. Conducts duties in accordance with industry federal and state billing guidelines and contractual obligations and in compliance with department policies and procedures.

As part of the Pharmacy Complex Claims team, we are able to bring traditional revenue cycle functions into the department of pharmacy which can provides significant opportunities for our health system. Key factors are hiring individuals with financial, pharmacy and medical revenue cycle expertise as a reimbursement solutions that identify and recover overlooked revenue for BMC.

Position: Claims Analyst

Department: Pharmacy Revenue Cycle      

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Ensure grievance and appeals are accurate and include the necessary elements for processing and resolving. Create clear and concise documentation to support written claim appeals. Identify all issues and required actions within the appeal in accordance with state and federal regulations.
• Reviews and appeal denials, had a working knowledge of the following,  (CPT, ICD 10, HCPC, Level II, and modifier coding, etc.) and is expert on prior authorization using FDA, National Comprehensive Cancer Network (NCCN), and for specialty clinics like inpatient chemotherapy hospitalizations, outpatient oncology visits, hospital based outpatient infusion centers for both oncology and non-oncology patients.
• Works closely and consistently with major pharmaceutical companies on new drug treatment guidelines/pathways, reimbursement, and drug replacement programs
• Possess excellent medical and billing terminology skills; Ability to read, analyze and interpret prescription drug orders.
• Proactively researches and understands payer issue, troubleshoot and resolve issues that impact revenue.
• Be considered an expert for high dollar drug appeals, by analyzing reports/ drug. In addition communicate denials trends to the administrative team, revenue cycle team, physician practice managers, and physicians to determine cause and suggests opportunities for improvement.
• Work closely with IT/Data infrastructure leads to implement tools to develop a flexible analytics environment
• Knowledge of Medicare and third-party codes and billing procedures as well as patient billing techniques.
• Effectively communicate issues and results via multiple media including in-person meetings, workgroups, verbal communication, email and presentations.
• Knowledge of Medicare and other regulatory billing codes and practices in order to assess billing for accuracy prior to submission to appropriate agency or company for processing and payment. Should be well-versed in regulatory guidelines and industry standards for Medicare and/or specific payer benefit providers.
• Collaborates with team and other revenue cycle departments to improve denials, avoidable write-offs,
• Applies analytical skills to pre-established work processes that may require 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 to organizational protocol with an emphasis on maximizing client satisfaction and provider profitability
• Utilize Hospital's Core Values as the basis for decision making and to facilitate hospital mission.
• Must adhere to all of BMC’s RESPECT behavioral standards.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job.  The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Bachelor’s degree in Business, Healthcare or closely related field or equivalent work experience.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Certified Pharmacy Technician (Preferred)
• Coding Certification CPC, RHIT (preferred)

EXPERIENCE:

• Preferred: 5-7+ years minimum recent experience in healthcare, coding, finance, revenue cycle, accounting and/or physician billing, preferably in a Medical Center setting, Oncology or Home/Office Infusion settings.
• Previous outpatient or community pharmacy experience preferred.

KNOWLEDGE AND SKILLS:

• Strong knowledge of claim edits NCCI (National Correct Coding Initiative (NCCI) Edits) and MUE (Mutually unlikely edits).
• Ability to converts pharmacy drug quantities into Medicare billing units according to Medicare Guidelines prior to submitting medical CMS1500 claim forms.
• Superior analytical skills to critically evaluate information gathered from multiple sources and synthesize into actionable information
• Strong interpersonal skills to elicit cooperation from a wide variety of sources, including upper management, clients, and other departments.
• Strong interpersonal skills with attention to detail and ability to organize, interpret, and present data.
• Must have a working knowledge of (CPT/HCPCS and ICD-10-CM-PCS diagnosis codes, understand current professional coder workflows, reviews principal, secondary diagnoses and procedures for hospital and physician (professional) services for inpatient, outpatient, and infusion records based on knowledge of coding systems). Knowledge of hospital and professional billing, collection and reimbursement requirements and standard practice.
• Must have working knowledge of drug NDC numbers and unit conversion
• SME (Subject Matter Expert) for complex denials and payment variances including contracts, fee schedules, and edits. Educates and provides feedback to various areas on Pharmacy Revenue Cycle rejection metrics and key performance indicators.
• Demonstrate pharmacy acumen, medication expertise, healthcare payer knowledge, medication guidelines to support prior authorization operations, reporting and analytics and quality management.

Equal Opportunity Employer/Disabled/Veterans

According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or “apps” job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.