Pharmacy Process Control Specialist-Pharmacy Business Office

The Process Control Specialist supports pharmacy-benefit revenue integrity across retail and specialty pharmacy services. The position is responsible for pharmacy claim review, reimbursement monitoring, audit coordination, billing issue resolution, rebilling activities, and identification of reimbursement improvement opportunities.

The role collaborates with Pharmacy Operations, Revenue Cycle, Compliance, Managed Care, Finance, 340B, and Information Technology to help ensure claims are billed accurately, payer requirements are understood, reimbursement concerns are investigated, and financial risk is identified and addressed.

This position serves as a pharmacy-benefit billing and reimbursement resource and supports the Pharmacy Business Office roadmap through revenue protection, audit readiness, pricing oversight, reimbursement monitoring, operational education, and continuous improvement.

Pharmacy-Benefit Claim Review and Revenue Integrity

• Review pharmacy-benefit claims for billing accuracy, appropriate claim submission, and reimbursement concerns.
• Monitor daily and recurring exception reports, including negative reimbursement, paid claim duplicates, rejected reversals, marked reversals, continuation-on-failure activity, bill-later claims, test claims, high-dollar claims, cash-plan use, workers compensation claims, and other identified exceptions.
• Review Medicare Part B and durable medical equipment claims for billing accuracy, overrides, required documentation, and potential compliance concerns.
• Investigate claim rejections, reversals, coordination-of-benefits issues, dispense-as-written code use, payer overrides, and other adjudication concerns.
• Coordinate rebilling and claim-correction requests and help drive identified issues through resolution.
• Identify recurring claim defects, reimbursement leakage, and operational trends that require education, workflow changes, or escalation.

Payer Audits and Compliance Support

• Coordinate commercial, government, pharmacy benefit manager, and other payer audit requests.
• Collect, review, organize, and track documentation needed for desk audits and claim-level audits.
• Maintain audit readiness through proactive claim monitoring, documentation standards, and operational education.
• Partner with Compliance, Legal, pharmacy leaders , and operational teams when payer requirements or billing practices require interpretation.
• Support standardized Medicare Part B documentation , checklists, procedures, and audit-preparedness materials.
• Track audit findings and assist with corrective-action follow-through.

Reimbursement and Pricing Monitoring

• Monitor reimbursement results and investigate underpayments, negative payments, unexpected patient responsibility, and other payment variances.
• Compare claim reimbursement with acquisition cost and available pricing information to identify potential margin concerns.
• Support pharmacy pricing monitoring, payer-rule review, and identification of reimbursement improvement opportunities.
• Escalate systemic payer, pricing, or configuration issues and collaborate with the appropriate teams through resolution.
• Assist with trend reporting, financial impact assessment, and measurement of corrected or avoided revenue loss.
• Support the Pharmacy Business Office feedback loop connecting payer terms, operational workflow, claim outcomes, payment, and margin.

Operational Support, Education, and Process Improvement

• Serve as a resource to retail and specialty pharmacy teams for billing, adjudication, rejection, rebilling, and reimbursement questions.
• Develop clear procedures, tip sheets, checklists, and education related to identified billing risks and payer requirements.
• Work with pharmacy leaders and frontline staff to standardize processes and reduce repeated billing defects.
• Identify opportunities to improve reports, workflows, controls, and issue-escalation processes.
• Participate in Pharmacy Business Office initiatives and cross-functional work related to pharmacy-benefit revenue integrity.
• Maintain organized documentation of investigations, decisions, follow-up actions, and completed improvements.

Required Knowledge and Skills

• Strong understanding of pharmacy-benefit claim adjudication from submission through reversal, rebilling, and final reimbursement.
• Knowledge of retail and specialty pharmacy billing workflows and common payer rejection scenarios.
• Knowledge of Medicare Part B, Medicare Part D, Medicaid, commercial payer, and pharmacy benefit manager requirements as they relate to pharmacy…