Pharmacy Revenue Integrity Analyst

Adventist Health • Roseville, CA

8d

About The Position

Supports accurate and compliant medication charging, billing, and reimbursement
across outpatient hospital departments such as observation units, emergency
departments, outpatient surgery centers, and infusion clinics. Ensures
medication-related charges are complete, accurate, compliant, and aligned with
Centers for Medicare and Medicaid Services (CMS), health resources & services
administration (HRSA), and payer regulations. Serves as the bridge between
pharmacy operations, revenue cycle, compliance, and finance, using deep
understanding of pharmacy workflows, coding, charge capture, and payer
requirements to prevent revenue leakage and mitigate compliance risks.

Requirements

• Three years' of experience in hospital or health system pharmacy, revenue integrity, billing, or compliance: Required
• State Pharmacy Technician license: Required (CA, OR, &/or HI): Required
• State Pharmacy Technician (PTC): Required

Nice To Haves

• High School Education/GED or equivalent: Preferred
• Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred
• Experience working in Epic Resolute, Cerner Revenue Cycle, or similar EMR/billing systems: Preferred
• Pharmaceutical Technician Board certification: Preferred
• Advanced certification (e.g., CHRI, CRCR, or 340B ACE): Preferred

Responsibilities

• Reviews and reconciles medication charges in outpatient hospital encounters (e.g., observation, infusion, surgery, emergency department (ED)). Validates NDC-to-HCPCS mapping, billable units, and appropriate modifiers (e.g., JZ/JW) per CMS and payer guidelines. Ensures compliance with 340B, GPO, and WAC pricing policies; collaborate with 340B Program Integrity teams to maintain audit readiness. Participates in internal and external audits (CMS, HRSA, internal compliance, or payer audits).
• Identifies and corrects charge capture errors prior to billing to ensure clean claims submission. Monitors UB-04 claim accuracy for outpatient medication billing and ensure HCPCS and revenue codes align with clinical documentation. Collaborates with revenue integrity, HIM, and pharmacy to maintain compliant and optimized CDM (Charge Description Master)/ Medication Record Master File (ERX) entries for medications.
• Stays current on CMS outpatient prospective payment system (OPPS) updates, HRSA guidance, NDC-to-HCPCS quarterly crosswalks, and payer-specific requirements. Supports resolution of claim denials related to outpatient drug charges, waste modifiers, medical necessity, or coding errors. Performs root cause analysis of denied or underpaid medication claims and recommend preventive actions.
• Partners with revenue cycle teams to adjust, rebill, or appeal denied medication claims when appropriate. Works with pharmacy procurement, buyers, and compounding teams to understand medication usage patterns, vial utilization, and potential billing impacts. Serves as a subject matter expert for medication charge capture during EMR upgrades, build validation, and workflow changes.
• Assists in the design and maintenance of charge automation rules and EMR charge capture mapping (Epic, Cerner, etc.). Educates pharmacy and revenue cycle staff on charge accuracy, 340B compliance, and billing best practices. Tracks and reports charge correction trends, denial root causes, and reimbursement impact. Identifies systemic issues and recommend process improvements to reduce recurring errors.
• Performs other job-related duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED