Talent Groups
Overview
Revenue cycle management (RCM) is the financial process that makes it possible for healthcare organizations to fulfil their mission of providing quality care for patients and communities. Pharmacy revenue cycle is a 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. Responsibilities
Under the direction of the Revenue Cycle Supervisor Pharmacy, the Revenue Cycle Claims Analyst is responsible, through extensive telephone and written correspondence, for pursuing insurance companies for payment or underpayment of services rendered. Substantiate accurate reimbursement through correct contract terms, billing practices and compliance with state and federal guidelines. Analyze, audit, problem-solve, and reconcile accounts as a critical capability for this position. Conduct 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, bring traditional revenue cycle functions into the department of pharmacy to provide opportunities for the health system. Focus on hiring individuals with financial, pharmacy and medical revenue cycle expertise as reimbursement solutions to identify and recover overlooked revenue for the client. Research, resolve, and prepare claims that have not passed payer edits daily. Determine and initiate action to resolve rejected drug claims. Serve as a subject matter expert for strategic provider relationships, service issues, reimbursement, and claims. Possess excellent medical and billing terminology skills; 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 prevent ongoing rejections. Know 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. Be well-versed in regulatory guidelines and industry standards for Medicare and/or specific payer benefit providers. Collaborate with team and other revenue cycle departments to improve denials and reduce avoidable write-offs. Apply 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 with organizational protocol with an emphasis on maximizing client satisfaction and provider profitability. Adhere to the hospital’s Core Values as the basis for decision making and to facilitate the hospital mission. 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 for monitoring and resolving Claims Work queues; specifically Front End, Referrals & Authorizations, and Clinical Workflow. Strong knowledge of claim edits NCCI and MUE. Ability to convert pharmacy drug quantities into Medicare billing units according to Medicare guidelines prior to submitting CMS-1500 claims. Ensures all billable services are processed in EPIC in a timely manner. Strong analytical skills to evaluate information from multiple sources and synthesize into actionable information. Strong interpersonal skills with the ability to elicit cooperation from a wide variety of sources, including upper management, clients, and other departments. Attention to detail and ability to organize, interpret, and present data; ability to tailor messages to the audience. Working knowledge of CPT/HCPCS and ICD-10-CM-PCS coding, hospital and professional billing, collection and reimbursement requirements and standard practices. Working knowledge of drug NDC numbers and unit conversion. Subject Matter Expert (SME) for complex denials and payment variances including contracts, fee schedules, and edits; can educate and provide feedback on Pharmacy Revenue Cycle rejection metrics and KPIs. Seniority level
Entry level Employment type
Contract Job function
Other Industries
Staffing and Recruiting
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Revenue cycle management (RCM) is the financial process that makes it possible for healthcare organizations to fulfil their mission of providing quality care for patients and communities. Pharmacy revenue cycle is a 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. Responsibilities
Under the direction of the Revenue Cycle Supervisor Pharmacy, the Revenue Cycle Claims Analyst is responsible, through extensive telephone and written correspondence, for pursuing insurance companies for payment or underpayment of services rendered. Substantiate accurate reimbursement through correct contract terms, billing practices and compliance with state and federal guidelines. Analyze, audit, problem-solve, and reconcile accounts as a critical capability for this position. Conduct 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, bring traditional revenue cycle functions into the department of pharmacy to provide opportunities for the health system. Focus on hiring individuals with financial, pharmacy and medical revenue cycle expertise as reimbursement solutions to identify and recover overlooked revenue for the client. Research, resolve, and prepare claims that have not passed payer edits daily. Determine and initiate action to resolve rejected drug claims. Serve as a subject matter expert for strategic provider relationships, service issues, reimbursement, and claims. Possess excellent medical and billing terminology skills; 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 prevent ongoing rejections. Know 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. Be well-versed in regulatory guidelines and industry standards for Medicare and/or specific payer benefit providers. Collaborate with team and other revenue cycle departments to improve denials and reduce avoidable write-offs. Apply 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 with organizational protocol with an emphasis on maximizing client satisfaction and provider profitability. Adhere to the hospital’s Core Values as the basis for decision making and to facilitate the hospital mission. 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 for monitoring and resolving Claims Work queues; specifically Front End, Referrals & Authorizations, and Clinical Workflow. Strong knowledge of claim edits NCCI and MUE. Ability to convert pharmacy drug quantities into Medicare billing units according to Medicare guidelines prior to submitting CMS-1500 claims. Ensures all billable services are processed in EPIC in a timely manner. Strong analytical skills to evaluate information from multiple sources and synthesize into actionable information. Strong interpersonal skills with the ability to elicit cooperation from a wide variety of sources, including upper management, clients, and other departments. Attention to detail and ability to organize, interpret, and present data; ability to tailor messages to the audience. Working knowledge of CPT/HCPCS and ICD-10-CM-PCS coding, hospital and professional billing, collection and reimbursement requirements and standard practices. Working knowledge of drug NDC numbers and unit conversion. Subject Matter Expert (SME) for complex denials and payment variances including contracts, fee schedules, and edits; can educate and provide feedback on Pharmacy Revenue Cycle rejection metrics and KPIs. Seniority level
Entry level Employment type
Contract Job function
Other Industries
Staffing and Recruiting
#J-18808-Ljbffr