United States onlyDepartment Overview
The Pharmacy Reimbursement Recovery and Payor Contract Rate Analyst provides analysis and demonstrate understanding of pharmacy revenue cycle management to maximize reimbursement. Review payment for accuracy, ensure collection according to contracts, understand and follow- up with hospital revenue reimbursement team to leverage the revenue process. Utilize preferred collection procedures to obtain insurance payments and ensure compliance with pharmacy payer contracts. Advocate on behalf of Pharmacy to ensure the most efficient processes regarding claim resolution. Evaluate denials and connect with hospital denial team to decrease medication-related claims denials, underpayment, and outstanding claims. Provide proactive and ongoing follow-up and problem solving with hospital reimbursement team. Identify trends, communicate proactively, and ensure accuracy in the process. Provide education to site and system stakeholders to drive optimal revenue capture.
The position requires minimal supervision with the ability to work independently, with an in-depth knowledge
of hospital pharmacy revenue capture and reimbursement. Creates a positive, constructive, and supportive
relationship between hospital patient revenue cycle departments, pharmacy operations departments, and
Managed Care Contract (MCC) department.
Provides training and mentoring to these areas as needed to drive optimal revenue reimbursement and
recovery. Assists with the development and enhancement of analytical tools for prospective and retrospective
audits and data analysis.
Function/Duties of Position
Pre and Post claims review audit to maximized reimbursement.
- Collaborate with hospital revenue cycle team, MCC team and Clinical team to request assistance (additional documentation, coding review, etc.) when necessary to successfully appeal an account. Ensures appropriate follow ups on accounts until a resolution is reached or all reasonable appeal options are exhausted.
- Proactively review charging processes for compliance documentation and coding
- Analyze and research Write-offs/denial report to ensure all avenues of appeals has been addressed
- Assess Self-Administered-Drugs to ensure Payors has exceptions in place for payments
- High-Cost medication and Single Case Agreement
- Inpatient new technology drug and report out to management
- Provide education to hospital revenue reimbursement team and other stakeholders to improve reimbursement
- For all tasks, attention to details, intense research, applying analytical thinking and continual follow-up are an essential expectation for successful outcome.
Provider payor contract rate analysis, work with MCC team in developing and maintaining up to date, accurate payment models to assist with the contract management processes (payment auditing and denial management) as well as reporting on current profitability, payor analysis and other key areas of analysis.
- Perform analysis of financial impact
- Assists with contract compliance and identify savings opportunities
- Collaborate and provide analysis to MCC Managers for payor contract renewals and methodology rate change requests
- Model medication by HCPCS codes and apply patient utilization for a total payor rate revenue impact
- Incorporate medication acquisition cost to determine profitability impact
- Provide counter proposal rates to improve profit margin For all tasks, attention to details, intense research, applying analytical thinking and continual follow-up are an essential expectation for successful outcome.
High-Cost Medication (Gene, Cell and BTM Therapy)
- Responsible for Charge Master Rate and Payor Contract Rate files
- Ensure new medications are added
- Model and provide Charge and expected Payor Contract rate for all new medications
- Support Single Case Agreement and other MCC inquiries for Payor rate support
- Support the Gene Therapy Committee request as needed
- Apply Pre and Post audit review to maximized reimbursement For all tasks, attention to details, intense research, applying analytical thinking and continual follow-up are an essential expectation for successful outcome.
Other duties as assigned Other Duties
Required Qualifications
Five years of experience with responsibility for program or project monitoring and coordination. The experience must have included program evaluation responsibility.
A bachelor’s degree in Business Administration, Management, Public Administration, or a field directly related to the position will substitute for two years of the required experience.
Job Related Knowledge, Skills and Abilities (Competencies):
- Advanced MS Excel, Outlook, Word and PowerPoint
- Proficient math skills
- Proficiency with Epic
- Analytical skills
- Organized task and follow-up items
- Ability to effectively work both independently and in a team environment; effective organizational abilities, oral and written communication skills, and interpersonal skills;
- ability to operate and communicate effectively while meeting multiple deadlines and completing projects simultaneously;
- ability to interact in a positive, productive manner with provider, nursing, pharmacy staff and leadership (demonstrating sensitivity, tact, and professionalism)
Preferred Qualifications
- Accounting, Finance or equivalent college level courses in finance
- Hospital and Community based experience with expertise in billing and compliance
- Healthcare reimbursement analysis, revenue cycle process knowledge experience and/or provider contract experience.
Job Related Knowledge, Skills and Abilities (Competencies):
- Ability to deal professionally, courteously and efficiently and to remain calm under stress. Proven ability to problem solve effectively.
- Ability to interpret third party remittances
- Ability to read and understand medical related terms
- Ability to perform basic pharmaceutical mathematics calculations
