Job Description

Job Title:                       Pharmacy Reconciliation Specialist   

Reports To:                   Director of Pharmacy   

Job Summary:                     Ensures establishment and maintenance of third-party contracts, credentialing of in-house pharmacies and reconciliation of third-party billing. May perform Pharmacy Technician duties as requested.

                                                                                                                                                                       

Qualifications and Requirements:

The requirements listed below are representative of the knowledge, skill, and/or ability required.  The job duties may be modified at any time based on business needs.

 

Essential Job Duties:

Pharmacy Technician

  • Receives and processes prescription orders and clinic supply requests promptly and accurately.
  • Completes prescription order transactions by billing appropriate payer(s) correctly after pharmacist verification.
  • Prints required pharmacy reports and labels.
  • Assists pharmacist with identification of prescription processing problems, proposing, and implementing solutions, and follow up.
  • Answers phone calls, responds to caller questions as able and/or transfers/ directs caller to appropriate phone number.  Takes messages for pharmacy staff as needed.
  • Prepares and facilitates daily and weekly bank deposits.
  • Maintains and file logs, records, and other required documentation accurately.
  • Ensures operation of pharmacy equipment by completing preventive maintenance and cleaning requirements, following manufacturer’s instructions, reporting malfunctions, and requesting repairs.
  • Completes and documents medication storage area inspections.
  • Participates in pharmacy staff and other meetings as required.
  • Performs administrative and/or clerical duties for pharmacy department as needed.
  • Working assigned weekends as required.

 

Reconciliation of Pharmacy Billing

 

  • Manages daily pharmacy payments systems, workflows and reconcile monthly pharmacy payer reports from Pharmacy system and third-party reconciliation vendor.
  • Reconciles paper remittance with third party vendor; creates and submits batch remittance of claims paid and/or reversals until 835 file set is done with carriers
  • Ensures pharmacy payers are enrolled to provide electronic payment remittance data through 835 files.
  • Works with third party reconciliation company to reconcile payments and update payer lists to match internal pharmacy systems.
  • Collaborates with the accounting department for reconciliation of claims and accounts receivable reporting.
  • Conducts site performance and payment audits. Collects transactional records, payment records, informational data (notes, prescriptions, forms, etc.) organizes and reports audit results.
  • Audits Contract Pharmacy third party administrators to ensure fees and charges match the terms of the contract.  

 

Third Party Contracting and Credentialing

 

  • Reviews and prepares third-party re-accreditation documents for Contract Review approval and Chief Executive Officer signature.
  • Supports contract and payer relations for the pharmacy ensuring that contract requirements are appropriately met, and contracts are kept up to date in Compliatric.
  • Assists in payer negotiation activities.
  • Works with payers to establish proper payment and processing procedures necessary for services.
  • Acts as subject matter expert in requirements, rules, and regulations of third-party and government payers.
  • Understands eligibility requirements and authorization requirements of insurance company plans, Medicare, and Medicaid, and how each program/payer reimburses.
  • Builds relationships with provider relations and claims processing managers within payer organizations. Communicates and resolves reimbursement issues and manages payer/provider relations between payers and pharmacy staff.
  • Creates and populates audit/analysis spreadsheets and/or databases. Produces reports for payment variances, rejected, denied, and reduced claims. Distinguishes between denials due to procedural errors and denials based on medical necessity issues and responds accordingly.
  • Coordinates appeals on denied claims according to time limits and set payer procedures.
  • Consistently analyzes operations and improves processes to provide better customer service and improve outcomes related to contracting and payer relations. Monitors performance of payer process to ensure correct policy and procedures are being followed. This includes auditing current processes; providing recommendations and assisting in implementing changes to ensure compliance.
  • Provides training and education to ensure optimal revenue cycle capture and contracting. Provides direction to staff in expected reimbursement.
  • Develops policies and procedures to guide and support provision of billable pharmacy services.
  • Provides decision support for contracting and acts as a liaison between Finance Department, third party contracting, Revenue Cycle, and pharmacy department, which may include analyzing proposed contracts and addendums for financial impact.
  • Provides solutions to contracting concerns that are brought forward. Researches and provides resolution to concerns. Evaluates and analyzes data to develop and implement recommendations. Resolves issues collaboratively to ensure the best outcome for the patient and health system.
  • Maintains files on payer denials and follows up to ensure that correct policy and contractual reimbursement procedures are being executed. Maintains billing process to ensure optimal reimbursements while adhering to regulations.
  • Prepares periodic reports for pharmacy staff identifying unbilled charges due to inadequate documentation.
  • Performs audits and analyses of payer denials; provides information on compliance issues arising from audits and formulates recommendations to providers regarding improved documentation practices to avoid future claims denials.
  • Assist in review, research, and responding to payer audits. Reviews audit requests. Coordinates audits with pharmacy operations and when necessary, conducts a pre-audit at the pharmacy prior to the payer audit. Evaluates audit results and develops audit response and correspondences with payer. Gives operational feedback to pharmacy staff to improve future audit results.
  • Acts as liaison between third party plans and Chiricahua 340B audit team during annual audits.
  • Monitors all staff licensure requirements; ensures competence skills assessments and annual Fraud Waste and Abuse training are completed. Manages new staff requirements and maintains a database of all required continuing education, immunization records and other information as requested by pharmacy leadership.
  • Works with pharmacy leadership team to maintain and update pharmacy policy and procedures as needed.
  • Complies with State and Federal statutes, rules, and regulations specific to pharmacy operation. Cooperates with Pharmacist in Charge, Director of Pharmacy and Lead Technician to resolve questions or issues regarding interpretation of rules.
  • Performs other duties as may be assigned by the Director of Pharmacy.

 

Required Education, Experience, Certificates & Licenses:

  • High School diploma or GED required.
  • Three years’ experience as Pharmacy Technician, Credentialing, Healthcare Billing or Healthcare Administration required.
  • Arizona Board of Pharmacy License as Certified Technician or Technician in Training required within three months of hire date required.
  • Fingerprint Clearance Card required.
  • Driver's License and Proof of Insurance may be required if requesting mileage reimbursement.

 

Preferred Education, Experience, Certifications & Licenses:

  • Two years’ experience with the 340B drug program preferred.
  • One year experience in credentialing and related experience in healthcare billing process preferred.
  • Bi-lingual in English and Spanish preferred.
  • Knowledge of Liberty and InMar software systems preferred

 

Required Language Skills:

  • Excellent verbal and written communication skills.
  • Ability to comprehend and compose instructions, correspondence, and communications in English in both oral and written format.
  • Adept at reading, writing, and interpreting technical documents and procedure manuals.
  • Ability to effectively present information in one-on-one and small group situations to patients, internal providers and staff and other agency staff working in cooperation with the organization.
  • Ability to communicate technical information to non-technical personnel.

 

Physical Requirements:

  • Ability to frequently exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to occasionally move about inside the workplace to access files, office machinery, etc.
  • Ability to traverse short distances indoors and outdoors between work sites.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer equipment, telephone, and other office machinery.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.
  • Ability to bend, stoop, kneel, reach, or otherwise position self to maintain equipment, install and maintain cable, including under desks and other narrow work areas.

 

Other Required Knowledge, Skills, and Abilities:

  • Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstracts and concrete variables.
  • Ability to compute rate, ratio and percent and to draw and interpret graphs.
  • Ability to skillfully gather and analyze data.
  • Ability to perform a variety of assignments with little or no direct supervision.
  • Deliver excellent customer experience in all interactions.
  • Displays high level of critical thinking and problem-solving skills.
  • Expert Computer proficiency required.
  • Knowledge of operation, principles, and techniques of installation, troubleshooting, and maintenance of a wide range of computer hardware and software.
  • Knowledge of research techniques, resources, methods, and procedures.
  • Knowledge of cabling practices and techniques.
  • Ability to learn and support new software and hardware in a demanding, multi-tasking environment.
  • Ability to prioritize and plan work activities, use time efficiently and develop realistic action plans.

 

Work Environment & Conditions:

  • Work environment is usually typical of an administrative office setting with no substantial exposure to adverse environmental conditions.
  • Work environment is occasionally typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
  • Work environment occasionally includes work in a server room with occasional proximity to electrical current, exposure to moving mechanical parts, cold environmental conditions, and cramped spaces.
  • Work is rarely performed outdoors but may include exposure to outside weather conditions to include heat and cold, and humid, windy, and dry conditions.
  • Work requires reliable transportation as position requires frequent travel and may occasionally require extended hours to include early mornings, evenings, holidays, and weekends.
  • Work requires ability to be contacted by cell phone during or outside of regular work hours.