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, 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. Advocate on behalf of FPS for efficient claim resolution processes. Evaluate denials, short-pays, and rejections. Provide proactive follow-up and problem solving with insurance companies and pharmacy sites to identify trends and ensure accuracy.
Understand workflow to proactively solve problems and evaluate trends in revenue cycle. Demonstrate analytical skills including reconciling payer remittances and understanding payer denials and their impact on revenue and margins. Resolve remittance issues such as unapplied cash, claim exceptions, and partial pays. Evaluate contracts and analyze payments to optimize the pharmacy claim payment cycle. Provide claims resolution to ensure process accuracy. Communicate with pharmacy site staff, revenue operations, and insurance companies to escalate and resolve payment discrepancies.
Analyze reimbursement arrangements and operational claims issues impacting financial results. Understand contracts to achieve department metrics like Days Service Outstanding (DSO), accounts receivable aging, and secondary billing timeliness. Ensure applied cash targets are met. Understand regulatory, payer, and billing requirements for claim preparation and processing.
Use data for financial projections and contractual analysis. Produce reports on payment variances, denied and partial pay claims. Review aging reports and generate billing resubmissions as necessary. Communicate reimbursement issues to coordinate payer-provider relations. Identify and communicate trends to leadership for revenue cycle performance improvement.
Assist in identifying potential compliance issues and recommend resolutions. Continuously evaluate and improve operations for customer service and revenue cycle efficiency. Attend meetings with payer representatives to discuss discrepancies and develop correction plans. Collaborate with leadership to develop process improvements that enhance efficiency, scalability, and margin. Use critical thinking to investigate and resolve work problems.
B.S./B.A. in Business, healthcare or related field or equivalent education and experience. Minimum 3 years experience in healthcare reimbursement analysis, collections, revenue cycle processes and/or pharmacy insurance. Strong interest in learning new information systems (Enterprise Rx, RMS StarLink, Frameworks LTC, Epic, Inmar). Excellent customer service and problem-solving skills. Proficient English language and competent math skills. Ability to work independently, prioritize workload fluctuations, and exercise independent judgment. Good computer and telephone skills.
Preferred: 5 years pharmacy reimbursement and collections experience with Medicare, Medicaid, PBMs and commercial health plans. Pharmacy dispensing knowledge or experience in infusion, retail, specialty, or hospital settings. Knowledge of third party payers, billing procedures, and insurance. Pharmacy Technician MN license.
Location
Minnesota, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
3 weeks ago