The Pharmacy Billing, Denials & Appeals Specialist coordinates and supports the Corporate Pharmacy department of RWJBarnabas Health efforts to reduce medication-related denials and maximize revenues for drug therapy and pharmacy related services as directed. The position is part of an interdepartmental collaboration within RWJBarnabas Health and requires frequent interactions with the health system's business office members as well as the local affiliate hospitals. The departments include, but are not limited to Revenue Cycle, IT&S, pharmacy informatics, pharmacy directors, managed care, compliance, oncology nursing, outpatient infusion and any areas where medications are administered. The Pharmacy Billing, Denials & Appeals Specialist also partners with Revenue Integrity to increase the accuracy and efficiency of the Pharmacy charge description master (CDM) for the entire health system. The position objectives are to provide support to Corporate Pharmacy and RWJBarnabas Health and maximize institutional revenue.
Primary Duties and Responsibilities
1. Researches medication-related insurance claim denials
2. Follows-up on unpaid or underpaid pharmacy claims
3. Ability to complete appeals to insurance payors
4. Monitors and reports outcomes of denials reviews and provides the recommendation for process improvements
5. Communicates denial and billing issues to affiliate sites as necessary
6. Performs technical review for medication formulary requests for Enterprise Clinical Information Systems (ECIS) Pharmacy Informatics & Revenue Integrity teams, include: CPT/ HCPCS & revenue codes for accuracy & validity All potential modifiers Medication billing units (J-codes) NDC billing data fields Obtains approval for all additions, inactivation's, changes and/or revisions made to the CDMCommunicates CDM changes to the appropriate facilities & individuals
7. Reviews all aspects of billing and collections processes (e.g. billing, coding, ECIS, collections, contractual adjustments, denials, compliance, etc.). Identifies areas of improvement across and within processes Formulates recommendations and assists with implementation of changes Verifies medication charges are documented appropriately in financial, clinical and operational areas (i.e. ECIS, medical records, charge forms, itemized bills)
8. Disseminates information as appropriate and prepares education sessions
9. Responds to ad hoc medication billing or reimbursement questions
10. Understands NDC requirements for state Medicaid and Managed Medicaid payors for billing hospital outpatient medications. Assists in the development of an automated process to comply with NDC requirements
11. Partners with Patient Accounting and Revenue Integrity to ensure denials and billing errors related to the Drug Chargemaster are addressed in a timely and accurate manner.
12. Analyzes and reviews drug and drug-related billing denials for medical necessity or any other coding specific denial reason. Reviews Remittance Advice (RAs) and Explanation of Benefits (EOBs) to assure appropriate reimbursement by payors Assures appropriate reimbursement by payors by comparing actual versus expected medication reimbursement rates Follows-up with Revenue Cycle team on resubmitted drug claims until the accounts are at a zero balance or expected payment is received by payor
13. Serves as an additional resource in the Cerner Millennium PharmNet Conversion pre and post-implementation phases.
14. Provides support in conducting medication billing audits to ensure that the Pharmacy Chargemaster or other operational changes result in optimum reimbursement.
15. Provides support in evaluating cost-effectiveness of new formulary additions based on health system payor mix, population demographics and reimbursement rates.
16. Maintains summary report of all projects submitted including projected reimbursement and recovered revenue.
17. Ensures medication billing complies with all billing guidelines and/or regulations including Medicare, NJ Medicaid, 340B and commercial payors.
18. Maintains medication replacement program and billing procedures with affiliate hospitals and vendor Assists in managing account holds and charge reversal processes Resource to affiliate hospitals on workflow process
Experience and Education Requirements
Bachelors required with three (3) years of medical coding/billing experience, and a background in business/finance in a health care organization is required OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE.
Requires broad training in fields such as hospital/medical office administration, pharmacy technician, nursing, billing or similar vocations generally obtained through completion of associate's degree program, pharmacy technician certification, or equivalent combination of experience and education.
Minimum Skills, Knowledge and Competency Requirements
- Prefer pharmacy or healthcare reimbursement experience
- Prefer hematology/oncology experience; medical/hospital coding, billing, and collections, drug reimbursement
- Knowledge base of Medicare rules and regulations (NCD/LCD), federal registry, Medicaid, insurance-based prior authorizations and clinical coverage guidelines
- HCPCS/CPT coding experience
- Ability to work independently with strong organizational skills; attention to detail, and follow through
- Ability to communicate effectively both orally and in writing
- Excellent project management skills
- Strong mathematical and analytical skills
- Knowledge of Microsoft Word and Excel required; Microsoft Access and Power Point preferred