Pharmacy Business Coordinator - Home Infusion - Billing & Revenue Cycle

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This position is responsible for conducting payer discussions, in-house financial audits, payer performance compliance, prepayment claims audit, CMS CERT audits, CMS Fraud, Waste, & Abuse audits, and auditing 3rd party payer compliance. They must maintain knowledge of revenue cycle operations, third party reimbursement procedures & regulations, payer relations, claims adjudication, contractual claims processing, medical terminology, and an understanding of the 340B Drug Discount Program. Knowledge will include at minimum, all aspects of payer relations, claims adjudication, contractual claims processing and general reimbursement procedures. Provides customer support and resolves problems that may arise as a result of customer inquiries. Supports the work of the department by completing reports and performing clerical duties as needed. Responsible for performing pharmacy related functions in compliance with departmental policies and procedures that provide optimal pharmaceutical care.



Additionally, the Pharmacy Business Coordinator may be responsible for securing registration data based upon comprehensive data elements, financial education/counseling, insurance verification, provision of clinical information for pre-certification, authorization and third party claims management. Interviews patient and arranges alternate methods of payment. Ability to calculate patient co- payments and deductibles based upon benefits processing.

MINIMUM QUALIFICATIONS:

EDUCATION, EXPERIENCE, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or Equivalent and Nationally Certified Pharmacy Technician (PTCB or EXPT) upon hire AND Two (2) years of healthcare related experience

OR

Associate's Degree AND One (1) year of healthcare related experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. PTCB Advanced Pharmacy Technician Certificate.

EXPERIENCE:

1. Three (3) years working in a specialty pharmacy.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Drafts various correspondence letters and sends to referral source when necessary.

2. Gathers and documents demographics, insurance information, needs assessment, and other data as needed.

3. Provides information and answers to patient/caregiver questions and refers to clinician when appropriate or requested.

4. Identifies all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.

5. Enters pre-registration using the comprehensive data elements into the registration/billing.

6. Contacts insurance company or employer to determine eligibility and benefits for requested services.

7. Performs medical necessity screening as required by third party payers.

8. Identifies managed care admission/treatment requirements and assures the requirements are met to guarantee payment of the account.

9. Initiates charge anticipation calculations. Accurately identifies anticipated charges to assure identification of anticipated

self-pay portions.

10. Communicates with the patient  the  anticipated  self-pay  portion  (co-payments/deductibles/co-insurance)  and establishes payment arrangements based on the Financial Policy and documents the financial resolution in the registration/billing systems.

11. Maintains current knowledge of major payor payment provisions and regulations.

12. Maintains registration accuracy threshold of 98% as identified in audit processing.

13. Participates in educational programs to meet mandatory requirements and identified needs with regard to job and personal growth.

14. Attends departmental meetings and/ or documents review of meeting minutes.

15. Participates in quality activities as assigned by Specialty Pharmacist Manager.

16. Participates in performance improvement (i.e. follows established work systems, id