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Pharmacy Billing Operations Manager

1 month ago

Round Rock, Texas, United States Regency Integrated Health Services Full time
Job Summary

We are seeking a highly skilled Pharmacy Billing Coordinator to join our team at Regency Integrated Health Services. As a key member of our billing department, you will be responsible for ensuring the efficient and timely billing process, including Facility Statements, Medicaid of Texas, multiple Third Party PDP's, and Prior Authorizations.

Key Responsibilities
  • Manage the completion of the billing process, including Facility Statements, Medicaid of Texas, multiple Third Party PDP's, Hospice, and Medicare B billing.
  • Submit claims and follow up with insurance companies.
  • Prepare and submit clean claims to various insurance companies electronically or by paper.
  • Resolve and work Third Party Rejections, knowledgeable with the use of LTC overrides and submissions.
  • Train and implement the use of Cover My Meds or designated system to process Prior Authorizations.
  • Reconcile third-party insurance claims.
  • Work with Scriptmax or designated claims analysis and reconciliation service weekly calls and reports.
  • Work all reports provided by Scriptmax, including AWP retro billing and price increases, Usual and Customary pricing, Generic Utilization and DAW reporting, Contract Assure, Low-Margin report, and Submission Clarification Codes submission.
  • Ensure compliance of all Short-Cycle regulations and submissions.
  • Challenge all Negative Gross Profits and MAC appeals with the Third Parties.
  • Complete EOM reports, including correct billing and reimbursement of all compounds, rebilling of claims billed to Medicare that should have been Hospice.
  • Profile and submit claims to all our Hospice PBMs.
  • Complete all contracts not handled by Innovatix, including contracting, credentialing, and reaccreditation with all Third Parties.
  • Manage Medicare B accreditation, billing, submission, and compliance.
  • Manage annual Fraud, Waste, and Abuse training and attestations to all Third Parties.
  • Manage all Audits and Appeals requested by Third Party PDP's, Medicare A census audits, State Board, DEA, and Medicaid of Texas requests for medical records and pharmacy records, Wholesaler, and Drug Inventory Audits.
  • Input all Third Party Plans into pharmacy system.
  • Provide Third Party Plans with Best Available Evidence.
  • Inform nursing homes of their residents needing to change Medicare-D plans due to loss of benchmarked status.
  • Assist families with Medicare-D enrollment, comparisons, selections, and understanding of Medicare-D plans.
  • Facilitate enrollment for Low-Income Subsidy recipients via Limited-Income Net PDP.
  • Manage as the Custodian of Records, completing and providing all requests of files, documents, and pharmacy records as requested for the use of legal actions by outside legal parties.
  • Conduct self in accordance with SSP's employee manual.
  • Maintain strictest confidentiality, adhering to all HIPAA guidelines/regulations.
  • Provide professional customer service to all customers.
Supervisory Responsibilities
  • Provide supervision of Billing Associates and assist in the hiring, wage reviews, and performance evaluations of Billing Associates.
  • Provide Billing Associates counseling and formal written documentation when needed.
  • Participate in education activities and attend Managers meetings.
  • Work closely with Innovatix and attend their Regional meetings, AR reviews, webinars, and legislative calls and sessions when required.
Qualifications
  • High school diploma or graduate equivalent degree (GED).
  • One year experience in LTC pharmacy or previous experience in related healthcare as Billing Manager and/or license technician.
  • Must be a registered certified technician or technician in training with Texas State Board of Pharmacy.