Pharmacy Billing Analyst - Fulltime - Bingham Farms

GENERAL SUMMARY:
Under minimal supervision, is responsible for resolving pharmacy adjudication rejections, as well as explaining COB related questions. Responsible for identifying and determining the accuracy and completeness of patient financial, insurance and demographic information, ensuring compliant claims to Third party payers, in accordance with established policies and procedures, as well as providing pharmacy support.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Accepts customer calls and provide accurate, satisfactory answers to their queries and concerns
• De-escalates situations involving dissatisfied customers offering assistance and support
• Accepts and processes all patient account payments.
• Provides support to internal and external customers regarding pharmacy copays, claim rejections, rebills, etc.
• Verifies patient insurance coverage and makes necessary changes in pharmacy system.
• Troubleshoots and resolves claim adjudication rejections for patients, physicians, pharmacies, and internal staff.
• Responds to insurance audits and claim reversals on behalf of all pharmacy sites, taking the proper steps to resolve receivables as a result of audit outcome.
• Identifies and resolves credit balances and understand the impact on patient responsibility and third party refunding.
• Monitors and manages various queues within pharmacy system.
• Evaluates and investigates claims on various reports to ensure proper billing and COB at pharmacy level.
• Submits third party medical and/or CMS1500 claim forms through the claims editing software. Understands the claim editing process and resolving the edits based on department procedures regarding claims submission.
• Converts pharmacy drug quantities into Medicare billing units according to Medicare Guidelines prior to submitting medical CMS1500 claim forms.
• Evaluates and investigates appropriation to be taken to submit automotive and worker's compensation claims, which includes verifying COB and billing demographics.
• Manually generates invoices and submit to each participating nursing home of the First Fill Program, following the evaluation of the proper billing and appropriation to bill all claims correctly.
• Meets established quality and productivity expectations.
• Identifies, resolves, and reports potential issues to leadership.
• Supports the standards set forth in the HFHS Code of Conducts by adhering to legal and ethical standards.
• Performs other related duties as assigned.