Pharmacy Revenue Cycle Analyst - Remote

Summary

The Pharmacy Revenue Cycle Analyst is responsible for ensuring optimal revenue capture for pharmacy services provided at Baptist Health to help maximize financial performance. The Pharmacy Revenue Cycle Analyst II will monitor revenue cycle performance by reviewing pharmacy charge capture, correctly capturing and coding pharmacy charges, ensuring accuracy of inpatient and outpatient claims processing and reviewing denials and write-off assessments. The Analyst II utilizes expertise in coding to ensure efficiency and excellence for patients and providers.

The Pharmacy Revenue Cycle Analyst II must be knowledgeable of pertinent pharmacy revenue cycle rules and regulations. This role will assist pharmacy leadership in developing and maintaining the payment models for managed care negotiations, payment auditing, and denial management.

• Ensures billing for all inpatient, outpatient commercial, Medicare, Medicaid, MCOs, and community pharmacy PBM accounts by analyzing, updating, and correcting claims data.
• Assures that billing procedures performed by the department are accurate and timely.
• Works collaboratively with accounts receivable through prompt and accurate billing, payment auditing, credits, and follow up of all patient accounts with Medicare, Medicare Advantage, Medicaid, PBMs, and MCOs.
• Coordinates with sites, managed care, and the business office to decrease medication-related claim denials, underpayments, and outstanding claims.
• Reviews, investigates, and processes high dollar and high dispense quantity work queue items.
• Serves as the system expert on medication-related compliance billing and charging.
• Performs quality reviews to ensure that pharmacy charge description master (PCDM) additions, inactivations, changes and/or revisions were accurately completed in the clinical and financial systems.
• Assists Baptist Health's pharmacy contract negotiating 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.
• Collaborates with clinical staff, other departments, and physician offices 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.
• Assists with contract compliance and identify savings opportunities.
• Responsible for working with IT and software vendor to test and implement software upgrades related to payment modeling software.
• Works with the revenue cycle team and pharmacy leadership to develop quality metrics and audit methodologies to drive accuracy and first-time quality for all HCPCS/CPT codes, revenue codes, billable units, multipliers, modifiers, and indications.
• Assists with the development and enhancement of analytical tools for prospective and retrospective audits and data analysis.
• Coordinates the overall maintenance of all pharmacy revenue cycle scorecards, dashboards and key performance indicators.
• Audits price file updates from wholesaler, non-wholesaler, Epic, charges, and patient information.
• Responsible for developing reports to highlight the proposed vs. actual financial impact by contract term.
• Provides education to site and system stakeholders to drive optimal revenue capture and compliance.
• Assists with development of policies, guidelines, and procedures for pharmaceutical coding, billing, pricing, charging, and denial management.
• Participates in committees, work groups, process improvement efforts, and educational initiatives.

• Bachelor's degree, and 3 years minimum job-related experience.
• 4 years additional experience may be substituted for a degree.
• Strong knowledge of general ledger accounts and coding.

• Accounting, Finance, or equivalent college level courses in accounting.
• Home Care Specialist-Diagnosis (HCS-D.
• Home Care Specialist - Oasis (HCS-O) or Certificate for OASIS Specialist - Clinical (COS-C).
• Hospital and Community based experience with expertise in billing and compliance.
• Experience in CDM maintenance.
• Direct experience in healthcare.

Baptist Health is an Equal Employment Opportunity employer.