Pharmacy Revenue Integrity

Pharmacy Revenue Integrity Auditor

Under the direction of the Director of Pharmacy the Pharmacy Revenue Integrity Auditor will serve as a pharmacy liaison and interface with finance, billing, revenue integrity, patient financial services, prior authorization teams, denial specialists, compliance, and other key stakeholders. This individual will serve as a subject matter expert in the setting of medication-related compliance billing and charging processes. They are responsible for ensuring the accuracy and compliance of pharmacy billing practices by reviewing patient records, medication orders, and insurance claims to identify and correct potential pharmaceutical billing errors. They are responsible for pharmacy billing work queues and the accurate submission or resubmission of pharmaceutical charges. This position collaborates with other department's charge champions to optimize pharmacy charging workflows and to decrease medication-related claim denials due to pharmaceutical charge errors. They will participate in audits, as requested, and will be responsible for maintaining relevant documentation and records. They will remain current with important billing and revenue related regulations and compliance. They will oversee medications charge structures that support billing accuracy, compliance and optimization.

Essential Duties and Responsibilities:

• Provide oversight of pharmacy billing work queues and accurate submission or resubmission for pharmaceutical charging.
• Maintain a thorough understanding of 340B program regulations and compliance requirements, staying up to date on policy changes and industry best practices to ensure accurate revenue integrity and optimal program utilization.
• Staying current with important billing and revenue related compliance and optimization topics to guide appropriate organizational decisions.
• Develop policies, guidelines, and procedures for pharmaceutical coding, billing, pricing, charging, and denial management to maximize reimbursement and compliant charging.
• Develop quality metrics and audit methodologies to drive accuracy and first-time quality for all HCPCS/CPT codes, revenue codes, billable units, multipliers, modifiers, indications, etc.
• Develop analytical tools to audit and analyze hospital pharmacy data elements to ensure accurate billing and maximal revenue capture.
• Perform quality reviews in order to ensure that PCDM additions, inactivations, changes and/or revisions were accurately completed in the hospitals clinical and financial systems.
• Participate and lead committees, work groups, process improvement efforts, and educational initiatives to improve pharmacy revenue integrity and the pharmacy billing cycle at a system level.
• Develop process flows, education, and communications to improve revenue integrity and compliance at a system level.

Qualifications:

• BS in Pharmacy, Information Technology, Business Management, Finance, Accounting or Hospital Administration - required
• MBA, MISM or Informatics Training - preferred
• 3 years of experience, hospital-based practice with experience in operations, infusion areas/centers, billing and compliance including direct experience with data analysis and pharmacy billing - required
• 5+ years of experience, experience with EPIC Willow, CDM maintenance, and automated dispensing machines (Pyxis/Omnicell) - preferred
• Epic experience - preferred
• Strong analytical skills
• Can work proficiently in Excel, EPIC and ADMs
• Strong clinical knowledge and clinical documentation practices
• Excellent verbal and written communication skills
• Strong critical thinking skills
• Detail oriented and ability to prioritize multiple tasks/projects when varying deadlines
• Engaged and collaborative team player, contributing to the overall success of team
• Experience utilizing MS office products

Physical Demands:

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Constantly
• Lifting - Rarely
• Carrying - Rarely
• Pushing - Rarely
• Pulling - Rarely
• Climbing - Rarely
• Balancing - Rarely
• Stooping - Rarely
• Kneeling - Rarely
• Crouching - Rarely
• Crawling - Rarely
• Reaching - Rarely
• Handling - Occasionally
• Grasping - Occasionally
• Feeling - Rarely
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Frequently
• Eye/Hand/Foot Coordination - Frequently

Working Conditions:

• Extreme cold - Rarely
• Extreme heat - Rarely
• Humidity - Rarely
• Wet - Rarely
• Noise - Occasionally
• Hazards - Rarely
• Temperature Change - Rarely
• Atmospheric Conditions - Rarely
• Vibration - Rarely

Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.