Claims Analyst Pharmacy Revenue Cycle

GTT•Boston, MA

6d•Hybrid

About The Position

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. 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.

Requirements

Excellent medical and billing terminology skills; ability to read, analyze and interpret prescription drug orders.
Knowledge of Medicare and third-party codes and billing procedures as well as patient billing techniques.
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.
Well-versed in regulatory guidelines and industry standards for Medicare and/or specific payer benefit providers.
Bachelor's degree in Business, Healthcare or closely related field, or equivalent work experience.

Nice To Haves

Certified Pharmacy Technician
Coding Certification CPC, RHIT

Responsibilities

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.
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.
Effectively communicate issues and results via multiple media including in-person meetings, workgroups, verbal communication, email and presentations.
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 the Hospital's Core Values as the basis for decision making and to facilitate the hospital mission.