Job Description

Job Description

Job Description

The Billing Specialist will report directly to the Director of Revenue Cycle Management. This role is responsible for managing financial transactions and billing processes within a pharmacy setting. It combines technical knowledge of pharmacy operations with expertise in billing systems and insurance claim management to ensure accurate and efficient reimbursement. This role entails managing and processing billing information related to pharmacy services while adhering to strict confidentiality protocols. The specialist will be responsible for ensuring compliance with all regulatory requirements concerning the handling of this sensitive data, safeguarding patient privacy, and maintaining the integrity of the company’s health records. Additionally, the role may involve collaborating with healthcare providers and insurance companies to facilitate accurate billing and resolve any discrepancies that may arise.

In this position, the Billing Specialist will be entrusted with access to sensitive company information, which includes Protected Health Information (PHI) and Electronic Protected Health Information (ePHI).

Job Responsibilities and Essential Functions

Billing and Claims Management:

· Efficiently process and submit insurance claims for both prescriptions and various pharmacy services, ensuring all necessary documentation is included to expedite approval.

· Resolve rejected or denied claims by carefully analyzing discrepancies, identifying the root cause of the issue, and resubmitting claims as necessary to optimize reimbursement.

· Verify patient insurance coverage and eligibility for prescribed medications by contacting insurance providers or utilizing electronic verification systems to ensure patients receive the medications they need without unexpected costs.

Patient Account Management:

· Manage patient accounts comprehensively, addressing billing inquiries, providing detailed explanations of charges, and processing payments in a timely manner to maintain financial balance.

· Assist patients in understanding their insurance benefits, including co-payment requirements, deductible obligations, and coverage limitations, ensuring they have a clear understanding of their financial responsibilities.

· Establish flexible payment plans tailored to individual patient needs, proactively addressing any outstanding balances to promote timely payments and financial resolutions.

Pharmacy Support:

· Work collaboratively with pharmacy staff to ensure the accurate and timely processing of prescriptions, fostering open communication to address any potential issues that may arise during the filling process.

· Provide assistance with medication authorizations and obtaining insurance approvals, ensuring that all necessary documentation is submitted and followed up on to minimize delays for patients in need of their medications.

· Update and maintain precise patient records and billing information, ensuring compliance with regulations and facilitating efficient workflow within the pharmacy.

Regulatory Compliance:

· Ensure strict compliance with HIPAA regulations and other relevant laws to protect patient privacy and maintain the integrity of sensitive information.

· Stay informed about ongoing changes in insurance policies, billing codes, and pharmacy regulations through continuous education and training, adapting practices accordingly to remain compliant.

Documentation and Reporting:

· Maintain meticulous records of all billing transactions and communications with patients and insurance companies to facilitate transparency and accountability.

· Generate comprehensive reports for management to assess billing efficiency, track revenue trends, and identify opportunities for improvement within the billing and claims process.

Required Qualifications

· A high school diploma or equivalent.

· A minimum of 3-5 years of experience in a specialty pharmacy setting.

· Familiarity with pharmacy software systems such as CPR+ and CareTend.

· Conducting outbound calls to the Pharmacy Benefit Manager to request approval overrides for medication prescriptions

· Strong understanding of medical and pharmacy billing practices, including ICD and CPT coding.

· Soft skills required:

o Excellent attention to detail and problem-solving skills.

o Effective communication skills for interacting with patients, insurance companies, and healthcare providers.

o Problem-solving abilities

o Time management

o Interpersonal skills

· Proficient in computer systems, including billing software, Microsoft Office Suite, and electronic health records (EHR) systems.

Preferred Qualifications

· Completion of a Pharmacy Technician Certification (CPhT), highly preferred

Physical Requirements, Screenings, and Work Location

Physical Demands: The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

· This position may be an in-office or remote role. As such, in-office employees will work onsite at our Lee’s Summit, Missouri location during regular business hours to allow for the highest level of collaboration with their team and other departments. Whether onsite or remote, the employee is required to work and be available during regular business hours to allow for the highest level of collaboration with their team and other departments.

· Must be able to lift and carry 20 pounds.

· Physical screening complete with no limitations to performing job duties.

· While performing the duties of this job, the employee is regularly required to sit and talk or listen.

· The employee is frequently required to stand, walk, use hands or fingers to handle, or feel and reach with hands and arms.

· Specific vision abilities required by this job include close vision and ability to adjust focus.

Other Duties

The job description and list of duties indicated above is not comprehensive. Duties, responsibilities, and activities may change at any time.

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