Senior Pharmacy Billing Analyst

Job Description

GENERAL SUMMARY:

Under minimal supervision, is responsible for Revenue Cycle Management, identifying and determining the accuracy of third-party payments, denials, and rejections, ensuring that claims are appropriately paid. Provides training and resources to all internal and external team members in accordance with department guidelines.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Accepts customer calls and provide accurate, satisfactory answers to their queries and concerns.
• De-escalates situations involving dissatisfied customers offering assistance and support.
• Provides support to internal and external customers regarding prior authorizations, pharmacy copays, claims rejections, rebills, etc.
• Verifies patient insurance coverage, coordination of benefits, and makes necessary changes within pharmacy operating systems to ensure accurate billing with optimal reimbursements.
• Troubleshoots and resolves claim adjudication rejections for patients, physicians, pharmacies, and internal Henry Ford pharmacy and medical team members.
• Responds to insurance audits and claim reversals on behalf of all pharmacy sites, taking the proper steps to resolve receivables as a result of audit outcome.
• Identifies and resolves credit balances and understand the impact on patient responsibility and third party refunding.
• Evaluates and Investigates claims on various reports to ensure proper billing and COB at pharmacy level.
• Submits third party medical and pharmacy CMS1500 claim forms through the claims editing software.
• Understands the claim editing process and resolving the edits based on department procedures regarding claims submission.
• Converts pharmacy drug quantities into Medicare billable units according to Medicare Guidelines prior to submitting medical CMS1500 claim forms.
• Manages and oversees all program details relating to First Fill Program, which includes contracts, prescription rebills, generating claim invoices, generating payment remits, posting checks, and follow-ups regarding delinquent balances.
• Posts all third-party payments through various forms of payment, which includes EFT, Deposit, and Lock Box.
• Utilizes reconciliation management software system to resolve delinquent third-party accounts, in accordance with insurance and department guidelines.
• Oversees Patient Financial Assistance Program, which includes, processing application and analyzing all information submitted to determine patient eligibility.
• Performs other related duties as assigned.

Qualifications

EDUCATION/EXPERIENCE REQUIRED:

• Associate degree required. • Minimum five (5) years of pharmacy experience required.
• Minimum five (5) years of Third Party/Revenue Cycle Management experience required.
• Medical billing experience preferred.
• Knowledge of Medicare Part-B Billing Guidelines.
• Ability to analyze and improve billing procedures required.
• Strong analytical and problem-solving skills required.
• Strong understanding and knowledge of medical/clinical and pharmacy terminology.
• Working knowledge of personal computers, and business software such as Microsoft Office.
• Organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and job duties/responsibilities.
• Strong interpersonal communication skills and experience with interacting with customers.

CERTIFICATIONS/LICENSURES REQUIRED:

• Pharmacy Technician License and Certification required.