Pharmacy Reimbursement Analyst

Fairview Health Services•Shoreview, MN

About The Position

Provide analysis and demonstrate understanding of pharmacy revenue cycle management to optimize the payment cycle for retail, specialty, compounding, and long-term care pharmacy claims. Ensure maintenance and understanding of the overall workflow of pharmacy accounts. Review payments for accuracy, ensure collection according to contracts, understand and follow-up with insurance companies to leverage the revenue process. Utilize preferred collection procedures to obtain third party payments and ensure compliance with Fairview Pharmacy Services (FPS) and Fairview Health Services (FHS) payer contracts. Ensure accuracy of FPS’ secondary billing processes and related vendor data feeds into FPS systems as required. Advocate on behalf of FPS to ensure the most efficient processes regarding claim resolution. Evaluate denials, short-pays and rejections. Provide proactive and ongoing follow-up and problem solving with insurance companies and pharmacy sites to identify trends, communicate proactively, and ensure accuracy in the process. Contribute to scalable process improvement to advance external revenue from the national strategy platform with pharmacy business office services.

Requirements

B.S./B.A. in Business, healthcare or related field or equivalent combination of education and related experience
3 years healthcare reimbursement analysis, collection experience, revenue cycle process knowledge experience and/or pharmacy insurance experience
This individual should have strong interest in learning new IS systems (Enterprise Rx, RMS StarLink, Frameworks LTC, Epic, Inmar, etc) as well as the ability to work independently
Excellent customer service skills, proficient in English language, capable of solving problems effectively, ability to follow policies and procedures, and competent mathematical skills
Strong critical thinking and analytical skills
Ability to work independently and exercise independent judgment
Ability to prioritize and deal with fluctuation in workload
Good computer and telephone skills

Nice To Haves

5 years pharmacy reimbursement analysis and collection experience with Medicare, Medicaid, Pharmacy Benefit Manager and Commercial Health Plan payer experience
Pharmacy dispensing knowledge and/or experience
Pharmacy experience in infusion therapies, retail, specialty and/or hospital setting
Knowledge of third party payers, billing procedures and insurance
Pharmacy Technician MN

Responsibilities

Understand the overall workflow to proactively solve problems, provide analysis and evaluate trends in the revenue cycle.
Demonstrates analytical skills including the ability to reconcile payer remittances.
Understands the payer denials and impact on FPS revenue cycle and overall margins.
Displays initiative to resolve 835 remittance issues including but not limited to; unapplied cash, claim exceptions and partial pays.
Evaluates contracts, analyzes payments and proactively problem solves to optimize the pharmacy claim payment cycle.
Provides claims resolution to ensure accuracy in the process.
Proactively communicates with pharmacy site staff, revenue integrity operations staff, and insurance companies (both pharmacy benefit managers and health plans) to escalate and resolve claims payment discrepancies.
Analyzes existing reimbursement arrangements/networks and reimbursement and operational issues with claims systems and their subsequent impact on financial results.
Understand contracts to achieve results and department metrics; including but not limited to: Payer Days Service Outstanding (DSO) equals or exceeds department goals, Open Accounts Receivable % aged greater than 60 days meets or exceeds department goals, Ensures timely submission of secondary payer billing which meets or exceeds department goals, Ensures applied cash targets are met for assigned payers.
Review payment for accuracy, ensure collection according to contracts, understand and follow-up with insurance payers (both pharmacy benefit managers and health plans) to leverage the pharmacy revenue cycle process.
Utilizes preferred collection procedures to obtain third party payments and ensures compliance with Fairview Pharmacy Services and Fairview Health Services payer contracts.
Ensures accuracy of FPS’ secondary billing processes and related vendor data feeds into FPS systems as required.
Understands regulatory, HMO, PPO, Federal, State and other third party payer requirements needed to prepare and or process claims.
Ensure optimal revenue cycle performance through evaluation, analysis and problem solving.
Uses data for projections as part of contractual analysis.
Completes detailed financial impact analysis of provider rate.
Produces reports for payment variances, rejected, denied and partial pay claims
Reviews aging reports that have reached certain aged categories (30, 60, 90 days, etc)
Generates manual and on-line billing for resubmission for third party payer’s outstanding balances.
Reviews payment process for accuracy; provides necessary follow-up.
Communicates and resolves reimbursement issues to coordinate payer/provider relations between payers and Fairview Pharmacy Services.
Identifies and communicates trends to PBO leadership to improve overall pharmacy revenue cycle performance
Provides analysis to stakeholders with explanations of reimbursement findings from assigned providers utilizing Excel and displays initiative to assist in identifying potential compliance issues to FPS staff and makes recommendations to Finance management for resolution.
Constantly analyzes operations, and attempts to improve processes in order to provide better customer service and improve the pharmacy revenue cycle (including minimizing controllable loss categories, i.e. Timely Filing)
Attend periodic meetings with payer representatives to discuss discrepancies and assist in developing action plan for correction.
Contribute to scalable process improvement to advance external revenue from the national strategy platform with pharmacy business office services.
Provides retail, specialty, compounding and long-term care pharmacy revenue cycle insights to venture partner teams and PBO vendors to assist with product/service improvement.
Collaborates with PBO leadership team to assist in the development of new process capabilities to improve efficiency, scalability and margin for FPS.
Uses problem solving and critical thinking to evaluate to identify, define, analyze and resolve work problems through investigation of alternative ideas and approaches.