Pharmacy Billing Analyst Details

Pharmacy Billing Analyst

Boston Medical Center - Quincy, MA

Employment Type : Full-Time

Under the direct supervision of the Revenue Cycle and Pharmacy Revenue Cycle Manager and according to department policies, procedures, and guidelines, is responsible for providing analytical support in all areas of pharmacy-related charges, costs and revenue. Tracks and reports various metrics as specified by department management. Monitors new and high-impact drugs for accurate charge capture and reimbursement. Tracks and reconciles medication prior authorization to paid claims, reporting results to stakeholders. The Billing Analyst-Pharmacy position requires minimal supervision and is able to work independently. Creates a positive, constructive, and supportive relationship between clinical areas, Revenue Cycle, and Pharmacy.

POSITION SUMMARY:

Under the direct supervision of the Revenue Cycle and Pharmacy Revenue Cycle Manager and according to department policies, procedures, and guidelines, is responsible for providing analytical support in all areas of pharmacy-related charges, costs and revenue. Tracks and reports various metrics as specified by department management. Monitors new and high-impact drugs for accurate charge capture and reimbursement. Tracks and reconciles medication prior authorization to paid claims, reporting results to stakeholders. The Billing Analyst-Pharmacy position requires minimal supervision and is able to work independently. Creates a positive, constructive, and supportive relationship between clinical areas, Revenue Cycle, and Pharmacy.

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Participates in Monthly committee meetings.

• Maintains a list of approved formulary additions for tracking purposes.

• Coordinates and identifies expected reimbursement of new formulary additions with the Payment Systems/Reimbursement department.

• Identifies charges of new formulary additions and evaluates for appropriate charge setup and claim submission.

• Gathers payment data and evaluates expected versus actual reimbursement on new formulary additions as well as other, high-impact drugs.

• Disseminates data on pharmacy charges, payments, and denials of drugs with medication prior authorization to all stakeholders.

• Identifies denials on approved medications and evaluates whether appropriate. If inappropriate, notifies stakeholders for remediation.

• Coordinates with Pharmacy Liaisons to gather patient-specific medication prior authorization data for tracking.

• Maintains current medication prior authorization records to ensure up-to-date information.

• Monitors charges and payment of high impact drugs, as they relate to their respective, current expenditures. Reports exceptions to key stakeholders for review.

• Coordinates with Pharmacy Purchasing to track monthly expenditures of specific drugs, as identified by Management.

• Reconciles purchases, charges, and payments of Management-identified drugs and reports discrepancies to key stakeholders.

• Liaises with Revenue Integrity, Patient Financial Services and Pharmacy Purchasing and eMERGE teams as necessary.

• Assists Pharmacy Revenue Integrity in drug charge code modifications and new drug set up, payer audit requests, and prior authorization and denial requests.

• Performs research and special project support as needed by management.

• Participates in hospital wide quality improvement activities.

• Conforms to hospital standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided.

• Utilizes the hospital's cultural beliefs as the basis for decision making and to support the hospital's mission and goals.

• Follows established hospital infection control and safety procedures.

• Adheres to all the principals of BMC's RESPECT Behavioral Standards.

• Responsible for the creation and maintenance of a healthy work environment. A healthy work environment is one where people feel supported, held accountable, where standards are applied and expectations are clear. A healthy work environment is one where leadership supports and leads, models behavioral standards and sets the example for how to do all things right. Critical responsibilities related to this:
  • Being engaged in the department, including managing up, owning team decisions and communicating and supporting departmental and or organizational initiatives.
  • Hold self and others to the highest ethical standards, and act with honor above all.
  • Effective human resource management, including effectively disciplining people, recognizing people, developing and performing performance evaluations and guiding people in professional development

• Develops competencies as related to position

Must adhere to all of BMC's RESPECT behavioral standards

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

Requires high school diploma or equivalent, Associates degree or BA/BS in Finance / Accounting or Medical Billing and Coding preferred.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

Current Certified Pharmacy Technician (CPhT) license is required.

EXPERIENCE:

• Minimum of 2 years' experience working within a pharmacy as a CPhT, required
• Minimum of 2 years' billing experience required, either in retail pharmacy billing or medical billing
• Inpatient or infusion pharmacy experience, highly preferred
• Revenue Cycle experience, highly preferred
• Experience working with reimbursement processes and workflows, highly preferred

KNOWLEDGE AND SKILLS:

Moderate understanding of insurance and billing for various pharmacy payers Knowledge of Medicare/Medicaid and private payer insurance programs as it relates to prior authorization of medical services, eligibility, and insurance billing methodology with HCPCS, CPT codes, and modifiers. Strong research, problem-solving, and analytical skills Knowledge of Microsoft Office programs Time management skills High level of independence and initiative Professional in conduct and demeanor Ability to perform multiple tasks and prioritize simultaneously Strong verbal and written communication
Req id: 16132