Pharmacy Revenue Optimization Specialist
2 weeks ago
The Pharmacy Revenue Integrity Analyst plays a critical role in ensuring optimal revenue capture based on reimbursement processes within our organization. This position is responsible for ensuring that claims are properly reimbursed and processed in accordance with third-party payer contracts and company policies and procedures.
Key Responsibilities:- Audits pharmacy location billing to customers, government, and third-party payers to ensure accuracy and compliance.
- Manages and implements pre-edit solutions via Script IQ to optimize revenue capture.
- Works post-edit reporting via Net RX, reconciling changes that need follow-up or correction to ensure seamless revenue cycle management.
- Supports pharmacy formulary review to ensure accurate product selection and acquisition values, promoting cost-effective delivery of medications.
- Partners with Regional Business Office Coordinators and pharmacy personnel for timely rebilling of suboptimal claims, ensuring revenue integrity.
- Evaluates gross margin reporting and ensures rebilling where applicable to optimize revenue capture, driving business growth.
- Analyzes prescription data and medication usage trends to identify opportunities for cost savings, streamline processes, and improve patient outcomes, generating reports and presenting findings to pharmacy and home office management to support decision-making.
- Supports pharmacy inventory count reconciliation related to revenue cycle management (RCM), ensuring accurate financial reporting.
- Reports process improvement and training opportunities to appropriate Operations, Procurement, and/or Revenue Cycle Management teams to improve revenue integrity, capture, and compliance.
- Works with cross-functional teams to decrease medication-related claim denials and outstanding claims, promoting a seamless revenue cycle.
- Education: High School / GED
- Experience: 1-3 years in LTC pharmacy
- Quality Assurance: Detail-oriented with a focus on accuracy and quality, with the ability to work independently in a fast-paced environment
- Licenses and Certifications: Certified Pharmacy Technician (CPhT) or similar credential preferred
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