Senior Manager, Pharmacy Services Revenue Integrity; Mount Sinai Healthcare System; Full Time; Days

The Senior Manager, Pharmacy Services Revenue Integrity develops and manages the people, tools/technologies and processes required to manage and improve financial performance of pharmacy services across the MSHS system through various activities including reimbursement and cost analytics, settlement reconciliation, and charge master maintenance and optimization.  This position is responsible for partnering across the system to bring together the administrative, financial, and operational resources and insight necessary to timely and accurately evaluate third party payor contract performance including reimbursement rates, direct and indirect remuneration (DIR) take-backs, and administrative and quality-based performance outcomes.   This position continuously identifies and leverages new technologies to improve quantitative and qualitative processes and analytical tools aimed at tracking and optimizing financial performance. Additionally, the position contributes directly to the development of an external revenue stream by creating and packaging scalable revenue integrity services and tools that support health system-based pharmacy operations. 

The position develops and directs the analytical techniques and tools used to monitor and report on reimbursement and related financial metrics.

I.    Payment Accuracy

•    Direct analysis of payment accuracy against contractual rates to identify discrepancies.

•    Develop, maintain, and implement best practices to ensure charge levels optimize third party payer reimbursement.

•    Identify, leverage, and manage technology systems to improve processes, track reimbursement performance and payment accuracy.

•    Lead communications with external payers on payment discrepancies, while informing key leaders of results, and collaborating with other departments as needed for.

•    Maintain in-depth knowledge of PBM contracts, Medicaid/Medicare services and reimbursement methodologies across all sites of care.

•    Develop, manage, and maintain a systematic transparent revenue integrity payment audit process, including tracking tools, metrics, and reporting

II.    Contract Negotiation Valuations 

•    Provide Contract leaders with payer reimbursement updates, market changes and trends

•    Track and evaluate business movement conversions and communicate results to leadership.

•    Provide advanced analytics on trends, benchmarks, and performance measures that identify areas that provide revenue enhancement opportunities

•    Use pharmacy revenue integrity metrics and standardized operating procedures to analyze proposed contracts addendums and product lines for financial impact.

•    Develop and maintain crosswalks for various payment methodologies including, AWP, WAC, and ASP.

III.    Financial Performance

•    Perform financial evaluations including measuring the impact of administrative and clinical performance-based criteria on takeback amounts.

•    Provides continuous education and subject matter expertise to leadership across the delivery system to help identify areas of focus and strategic direction.

•    Responsible for the integrity and accuracy of financial documentation that supports pharmacy services optimization across the organization.

•    Partner with operations leadership to ensure the administrative and clinical performance measurements are achievable.

•    Manage the process to track performance of all pharmacy services related payer contracts.

IV.    Charge Optimization  

•    Develop and manage the processes, tools, and procedures to analyze charge levels against third party payer contract rates.

•    Work closely with operations to ensure accuracy and consistency/standardization when setting charges.

•    Lead charge optimization analytics to support financial performance.

V.    Business Operations Support

•    Develop and maintain standardized processes to identify and track top contracts, top lines of business and payer mix.

•    Continuously develop processes and tools to enhance revenue that leads to new products and services.
•    Create new analytical models and intellectual property that helps the revenue integrity team differentiate itself in the marketplace when it comes to leading new products and services.

•    Maintain up to date technical knowledge through educational workshops, user groups and reviewing publications.

•    Report pharmacy services related metric to leaders. 
 

• Doctor of Pharmacy Required.
• MBA or JD preferred. 
• 10+ years of related pharmacy experience with special consideration given to pharmacy contract valuations, pharmacy services financial analysis, healthcare reimbursement and payment methodologies and pharmacy site operations required. 
• 3+ years’ experience managing and leading a team required. <