Pharmacy Billing Technician

Great Plains Tribal Leaders Health•Rapid City, SD

6d•Onsite

About The Position

The Pharmacy Billing Technician performs a full range of pharmaceutical billing duties, including submitting pharmaceutical claims to third-party payers and responsible parties using the RPMS Pharmacy Point of Sale system. This role involves rebilling or correcting previously submitted claims, performing various clerical tasks, and assisting billing staff with inquiries about unpaid pharmacy claims. The technician will analyze, maintain, and direct operations for the pharmacy point-of-sale program, approve, edit, and override pharmacy claims in the RPMS POS system, and research and enter eligibility for new pharmacy insurance plans. They will also research and verify patient insurance, coordinate benefits, complete insurance data for patient claims, process and correct accounts, verify diagnosis and authorization codes, identify liability and guarantors, interpret Explanation of Benefits (EOBs), and analyze billing components. Additionally, the role includes submitting prior authorizations, reviewing denied claims, answering questions from relatives, staff, and insurance companies, and running/monitoring various POS reports to identify trends and problems. The technician will maintain accuracy in RPMS NDC’s and cost, utilize ScriptPro for verification and research, and assist Pharmacy Supervisors in maintaining RPMS Pharmacy Drug Files. This position handles all pharmacy audits, maintains records for 7 years, conducts internal audits to mitigate fraud risk, and answers correspondence requesting information. They will notify their supervisor of unbillable claims, serve as a POS technical resource, provide training to billing staff, and collaborate with pharmacists on formularies. The role also involves maintaining lists of uninsured relatives, high-dollar medications, and insurance information to prevent duplicate fills and adverse reactions. The technician must attend monthly POS webinars, comply with HIPAA, perform duties accurately and timely, maintain attendance, communicate effectively, and utilize required systems. Compliance with federal laws and regulations is mandatory.

Requirements

Completion of a formal training program or an associate’s degree and one (1) year relevant experience; or, a high school diploma or GED and three (3) years of relevant experience.
Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Must comply with all job-related employee health screening and immunizations prior to your first day of employment.
Documentation of completed immunizations prior to first day of employment: MMR, Varicella, Hepatitis B, Influenza, T-dap, and COVID-19 vaccination.
Ability to perform the essential functions of the job, with or without reasonable accommodation.
Requires the ability to sit for extended periods and regularly use standard office equipment such as a computer, keyboard, telephone, and copier.
Occasional standing, walking, bending, and reaching may be required.
Ability to lift and carry office materials or supplies up to 25 pounds occasionally.
Requires manual dexterity and visual acuity for computer use and document review.
Must be able to read, write, speak, and hear.
The employee must comply with all organizational policies, procedures, and applicable laws and regulations.

Nice To Haves

Tribal preference laws followed by GPTCHB.
Qualified Indian/Tribal candidates given preference over overqualified non-native candidates if all other qualifications are equal.

Responsibilities

Perform pharmaceutical billing technician duties, including submission of claims to third-party payers and responsible parties using the RPMS Pharmacy Point of Sale system.
Rebill or correct billing of accounts previously submitted.
Perform various clerical tasks and assist billing staff with questions on unpaid pharmacy claims.
Analyze, maintain, and direct operations for the pharmacy point-of-sale program.
Approve, edit, and override pharmacy claims for the OHC in RPMS POS system.
Research, enter, and run eligibility on new pharmacy insurance plans to RPMS using different insurance portals.
Research and verify patient insurance for all pharmacy insurances when encountering errors during edit of claims in RPMS.
Coordinate benefits, verify data, and give appropriate information to the PBC/PSR staff.
Complete insurance data for patient claims; process, research, and correct accounts; verify diagnosis and authorization codes; identify liability and guarantors; interpret Explanation of Benefits (EOBs); and analyze billing components.
Submit prior authorizations for all prescriptions requiring a prior authorization in the Pharmacy using Cover My Meds.
Review all denied claims to determine if a claim was denied incorrectly.
Answer questions from relatives, staff, and insurance companies.
Run, maintain, and monitor POS reports including STRANDED, MISS OPPORTUNITY, DUPE CLAIM REPORT, CORRUPTED REPORT monthly, notifying the business office manager of any trends or problems, notifying technicians of errors, and contacting third party providers when necessary.
Run a Before and After back bill report which generates rejected claims to be worked weekly.
Run a rejected claims report to be worked daily.
Maintain accuracy in RPMS NDC’s and cost and remove any inactive NDC.
Utilize ScriptPro regularly to verify accurate NDC, dispense, mail, and research information for audits to provide proof of dispense.
Assist Pharmacy Supervisors in the maintenance of the RPMS Pharmacy Drug Files in the computer system for billing purposes, such as updating NDC numbers and “re-matching” drugs to the National Drug File (NDF) when necessary.
Handle all pharmacy audits including individual and desktop, maintain record keeping for 7 years (researching, gathering information, creating reports).
Conduct internal audits to mitigate the risk of fraud.
Answer all correspondence requesting information on provider or relative.
Notify supervisor of all claims deemed unbillable along with reason(s) on a daily basis.
Serve as a POS technical resource, provide orientation, and provide ongoing training and education to billing staff.
Work closely with pharmacists to collaborate on formularies.
Maintain a list of uninsured relatives who routinely receive high dollar medications, shared with PBC to capture revenue if insurance changes.
Maintain a list of high dollar medications that South Dakota Medicaid allows a resubmission above the all inclusive rate.
Maintain a list with the pharmacist of relatives who have insurance that fill at outside pharmacies to prevent duplicate fills and potential adverse reactions.
Attend monthly POS webinars to remain knowledgeable, ask questions, or keep up on new patches.
Comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
Perform related duties as assigned.
Perform the core responsibilities of the position accurately, timely, and in accordance with established standards.
Maintain regular and reliable attendance consistent with the position’s schedule and operational needs.
Communicate effectively with internal and external stakeholders as required by the role.
Adhere to all applicable policies, procedures, and regulatory requirements.
Utilize required systems, tools, and technology necessary to perform the job.