Pharmacy Revenue Cycle Analyst II - Remote

Job Description:

Baptist Health is looking for a Remote Pharmacy Revenue Cycle Analyst II to join our Pharmacy team!

• 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.
• Review and analyze clinical documentation for home health services to assign accurate and compliant ICD-10, CPT, and HCPCS codes.
• Communicate with clinical staff to clarify diagnoses, procedures, and services.
• Ensure coding is compliant with CMS guidelines, OASIS assessments, and home health-specific regulations.
• Collaborate with agency leadership, clinicians and billing staff to resolve coding-related denials and rejections.
• 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.
• Collaborate with agency leadership, clinicians and billing staff to resolve coding-related denials and rejections.
• Ensure all coding is completed timely.
• 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.
• Collaborate with clinical and billing staff to ensure proper documentation.
• Serve as a resource for clinicians as it relates to OASIS, coding, and PDGM guidelines.

QUALIFICATIONS

REQUIRED:

* Associate's degree in nursing.

* 2 years of work-related experience.

* Strong knowledge of general ledger accounts and coding.

* One of the following certifications is required:

• Home Care Specialist-Diagnosis (HCS-D); Home Care Specialist - Oasis (HCS-O) OR
• Certificate for OASIS Specialist - Clinical (COS-C)

* Must obtain HCS-D Certification within twelve months of hire.

* Must obtain COS-C or HCS-O Certification within twenty-four months of hire.

PREFERRED:

* Hospital and Community based experience with expertise in billing and compliance.

* Experience in CDM maintenance.

* Direct experience in healthcare.