Pharmacy Billing Specialist

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Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview
The Pharmacy Billing Specialist supports accurate and compliant billing for pharmacy services by reviewing data, monitoring key processes, and identifying areas for improvement. This role ensures consistency in charge capture, claims submission, and reimbursement to safeguard revenue and minimize risk. The specialist is responsible for maintaining compliance with billing and pricing requirements for both commercial and public payers. Additional duties include developing audit templates, performing routine compliance monitoring, analyzing data to identify discrepancies, and leading or participating in process improvement initiatives.

Locations
Stanford Health Care

What you will do

• Designs, performs, and revises daily, weekly and monthly compliance verification of pricing and charges.
• Reviews and analyzes pharmacy billing data, including but not limited to charges and claims, to identify discrepancies, trends, and compliance gaps.
• Participates in/leads identified process improvement opportunities by providing data-driven insights and supporting/leading implementation of corrective actions as appropriate.
• Develops and contributes key performance indicator (KPI) data to the Pharmacy Billing Dashboard. Assist in maintaining dashboard.
• Collaborates with pharmacy and SHC revenue cycle teams to resolve billing issues and strengthen compliance with payer requirements.
• Assists with reimbursement optimization and denial prevention through timely issue identification and follow-up.
• Supports regulatory audits and other compliance requirements.
• Acts as the subject matter expert for all pharmacy billing programs.
• Responds to inquiries related to billing compliance issues. Researches applicable regulations/standards and provides appropriate guidance. Develops repository of inquiries and responses for future reference.
• Works collaboratively with other pharmacy business operations team members to assist with other duties as needed.
• Research activities (e.g. abstracts, posters, publications) are encouraged.
• Attends Pharmacy Management meetings to communicate issues with billings, charges, and claims.
• Leads various billing steering committees and other large group meetings as it related to pharmacy billing.
• Communicates and educates Clinic Administration, Clinic Managers and clinic staff on pharmacy-related issues such as regulatory changes/compliance, FDA drug recalls, drug information, special programs, sample medications, investigational studies, and other related medications.
• Coordinates with pharmacist and pharmacy technicians to develop and maintain standard work and operating procedures.

Education Qualifications

• PharmD Degree from an accredited college/university required.

Experience Qualifications

• Five (5) years of progressively responsible and directly related work experience required.

Required Knowledge, Skills and Abilities

• Implementation of a large-scale initiative that requires cross-functional coordination.
• Knowledge of healthcare regulations and policies affecting pharmacy billing, reimbursement, and financial compliance at both federal and state levels.
• Knowledge of other relevant regulatory guidelines (e.g., CMS, 340B, FDA).
• Knowledge of theories, principles, practices and techniques of personnel management, including selecting, training, directing, evaluating, and supervising employees.
• Knowledge of and demonstrated proficiency in the use of the Microsoft Suite of software applications (Word, Excel, PowerPoint, Visio, Access, Project and Outlook).
• Knowledge of financial operations and billing
• Knowledge of project management process and systems.
• Knowledge of healthcare regulatory climate.
• Ability to mediate and resolve complex problems and issues.
• Ability to develop financial budgets and manage expenses.
• Ability to develop long-range business plans and strategies.
• Ability to develop and maintain productive and cooperative work relationships at all levels both within and outside the organization.
• Ability to communicate effectively at all organization levels and in situations requiring instructing, persuading, negotiating, conflict resolution, consulting and advising as well as prepare clear, comprehensive written and oral reports and materia