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 Pharmacy Revenue Cycle

Department: Pharmacy Revenue Cycle

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• 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 to prevent ongoing rejections.

• 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:

• 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.

KNOWLEDGE AND SKILLS:

• Requires 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.

• Responsible to monitor and resolve Claims Work queues; Specifically, Front End, Referrals & Authorizations, and Clinical Workflow.

• 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.

• Ensures all billable services are processed EPIC in a timely manner.

• 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 be able to present information effectively in both written and oral forms, tailoring messages to the audience.

• Understanding and knowledge of the business, products, programs, corporate organizational structure (including functional responsibilities), and basic research principles/methodologies

• 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.

Compensation Range:

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being. 

NOTE: This range is based on Boston-area data, and is subject to modification based on geographic location.

Equal Opportunity Employer/Disabled/Veterans

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