Saint Barnabas Health Care System Pharmacy Billing, Denials & Appeals Specialist in Oceanport, New Jersey
Pharmacy Billing, Denials & Appeals Specialist
Req \#: 0000067560
Facility: RWJBarnabas Health Corporate Services
2 Crescent Place, Oceanport, NJ 07757
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
Researches medication-related insurance claim denials
Follows-up on unpaid or underpaid pharmacy claims
Ability to complete appeals to insurance payors
Monitors and reports outcomes of denials reviews and provides the recommendation for process improvements
Communicates denial and billing issues to affiliate sites as necessary
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 CDM
Communicates CDM changes to the appropriate facilities & individuals
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)
Disseminates medication-related regulatory/coding/billing information to internal customers
Responds to ad hoc medication billing or reimbursement questions
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
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.
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
Serves as an additional resource in the Enterprise Clinical Information System (i.e. Cerner Millennium, AllScripts, Epic) pre and post-implementation phases.
Provides support in conducting medication billing audits to ensure that the Pharmacy Chargemaster or other operational changes result in optimum reimbursement.
Provides support in evaluating cost-effectiveness of new formulary additions based on health system payor mix, population demographics and reimbursement rates.
Maintains summary report of all projects submitted including projected reimbursement and recovered revenue.
Ensures medication billing complies with all billing guidelines and/or regulations including Medicare, NJ Medicaid, 340B and commercial payors.
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
High level of curiosity, self-motivation and attention to detail
Strong mathematical and analytical skills
Ability to work independently with strong organizational skills
Ability to communicate effectively both orally and in writing
Excellent project management skills
Knowledge of Microsoft Word and Excel required; Microsoft Access and Power Point preferred
We offer a great work environment, competitive rates and excellent benefits, including:
Vacation/Personal/Holiday/Sick Time Off
Short & Long Term Disability
Basic Life & Accidental Death Insurance
Health Care/Dependent Care Flexible Spending Accounts
RWJBarnabas Health is an Equal Opportunity Employer.