Pharmacy Audit and Reconciliation Specialist

The Ohio State University

1d

About The Position

The Revenue Integrity Specialist optimizes the payment cycle for retail and specialty pharmacy claims. This role ensures accurate workflow of pharmacy accounts, reviews payments for accuracy, aligns collections with contracts, and follows up with insurance companies. The specialist secures third-party payments, ensures compliance with payer contracts, and maintains accurate secondary billing processes and vendor data feeds. They advocate for efficient claim resolution, provide proactive follow-up, and identify trends to ensure process accuracy. Additionally, they contribute to scalable process improvements, respond to and defend audit requests from commercial health plans/payors, and ensure the accuracy and completeness of claims to retain reimbursement.

This position assists with revenue cycle related activities. These activities include but are not limited to reconciling payer remittances including unapplied cash, claim exceptions and partial pay understanding, payer denials and impact on revenue cycle, proactively communicate with onsite pharmacy staff, finance staff and insurance companies to resolve payment discrepancies. Advanced knowledge of, or experience with state, federal and PBM (Pharmacy Benefit Management/commercial health plans/payors) accreditation rules and regulations regarding pharmacy benefit and medical benefit claims billing. This position requires strong knowledge of Microsoft Excel, Microsoft Teams and other computer related skills.

Requirements

• Bachelor’s in Business, healthcare or related field or equivalent combination of education and related experience or 2 years of relevant experience required.
• Must be registered technician with the State of Ohio Board of Pharmacy and hold active PTCB/NHA certification prior to start date.
• PTCB certification and Board of Pharmacy registration as a Certified pharmacy technician must be maintained for continued employment
• Strong knowledge of Microsoft Excel, Microsoft Teams and other computer related skills.

Nice To Haves

• 2 to 4 years of relevant experience preferred.
• Advanced knowledge of, or experience with state, federal and PBM (Pharmacy Benefit Management/commercial health plans/payors) accreditation rules and regulations regarding pharmacy benefit and medical benefit claims billing.

Responsibilities

• Ensures accurate workflow of pharmacy accounts.
• Reviews payments for accuracy.
• Aligns collections with contracts.
• Follows up with insurance companies.
• Secures third-party payments.
• Ensures compliance with payer contracts.
• Maintains accurate secondary billing processes and vendor data feeds.
• Advocates for efficient claim resolution.
• Provides proactive follow-up.
• Identifies trends to ensure process accuracy.
• Contributes to scalable process improvements.
• Responds to and defends audit requests from commercial health plans/payors.
• Ensures the accuracy and completeness of claims to retain reimbursement.
• Reconciles payer remittances including unapplied cash.
• Understands claim exceptions and partial pay.
• Understands payer denials and impact on revenue cycle.
• Proactively communicate with onsite pharmacy staff, finance staff and insurance companies to resolve payment discrepancies.

Benefits

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.
• Paid time off, including sick and vacation time and 11 holidays.
• State retirement plan or an alternative retirement plan, both with generous employer contributions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees