Pharmacy Reimbursement Specialist

Job Title

Scope of Responsibilities:
Works under minimal supervision within Accounting and Finance department to ensure timely review of data for reporting to stores, outside Third-Party Business partners, as well as government agencies. Prepares reports and maintains various files and information for the department ensuring proper reimbursement. Works collaboratively within the department to ensure licensing, credentialing and all necessary paperwork are in place for billing.

Job Summary:

Assists and supports the Accounting and Finance department in the achievement of Rx sales, gross margin according to plan.

This is not a remote opportunity and will be in office only.

Job Duties:

• Responsible for reviewing, identifying and correcting billing issues based on contractual agreements.
• Responsible for PBM related billing communications regarding better reimbursement strategies and issues faced to all locations.
• Assist in auditing plans to verify contractual compliance.
• Responsible for monitoring MAC pricing and submitting MAC appeals daily and developing and maintaining MAC reporting and analysis.
• Responsible for using daily/weekly/monthly reports for Third Party billing and pricing accuracy to maintain the highest level of profitability. Working with the Pharmacy Business Analyst to develop reporting as needed to gain efficiencies and improve profitability.
• Responsible for monitoring and sending claims via the AWP resubmission tool and analysis reporting of outcomes.
• Responsible for reviewing, analyzing, and developing edits internally and through our switch that can improve efficiencies and/or profitability.
• Assist Third Party Administrator/Reimbursement Supervisor with licensing, credentialing, and Third-Party training programs.
• Assist in the development and preparation of all claims related and profitability reporting.
• Responsible for resolving Third Party pharmacy questions received from Store Systems Help Desk.
• Responsible for yearly immunization configuration, reporting and analysis.
• Assist Third Party Administrator/Reimbursement Supervisor in the review of plan set up within the pharmacy application.
• Responsible for completing all mandatory and regulatory training programs.
• Perform other duties as assigned.

Experience Preferred:

• Previous experience in retail pharmacy, Third Party operations, and/or Finance/Accounting

• Minimum:
  High School Diploma or GED
• Preferred: AS Degree or Higher in Business Administration, or related field

Special Conditions of Employment:

• Drug Test
• Initial and continuous exclusion and sanction/disciplinary monitoring

Compensation

$18.50 - $21.00 per hour

The final offer will be determined after careful consideration of multiple factors such as relevant skills, years of experience and education.

KPH Healthcare Services, Inc. is a multistate organization and abides by all local, state, and federal regulations as it pertains to minimum wage requirements.