FT, Mon - Fri, 8:00 am - 4:30 pm

We are currently searching for a Pharmacy Billing Specialist responsible for maximizing reimbursement for infusion drugs provided by the Children’s Home Health Care pharmacy. Responsibilities will include attaining and maintaining a comprehensive and up to date understanding of the constantly changing insurance requirements related to infusion drug therapy, to include appropriate and timely communication with CHHC staff. Accurate intake, authorization and billing will be the responsibility of this position.

Essential Functions

• Obtain accurate and complete authorizations for all pharmacy charges, to include equipment, per diems and accurate HCPCS, CPT and NDC codes for the drugs and items provided.
• Verify insurance coverage to include any applicable requirements related to limitations, prior authorization, pharmacy benefit plans, specialty pharmacy, exclusions, preferred drug lists, diagnosis, lack of coverage, etc.
• Coordinate with Pharmacy on test claims.
• Communicate with Supervisor and Pharmacy regarding coverage concerns.
• Actively participate in daily pharmacy report meetings. Proactively being aware of upcoming refills and their authorization status and discussing any issues that may be of concern prior to providing the drug whenever possible.
• Research payer requirements for infusion drugs to determine if the prescribed drug is on the payers preferred drug list, subject to a manufacturer rebate, only covered for certain conditions/age/sex or other requirements and restrictions. Communicate findings to the pharmacy when applicable to ensure the appropriate drugs are dispensed to maximize reimbursement results.
• Coordinate with physician offices on special authorization requirements for various infusion drugs, facilitating peer to peer reviews as necessary
• Achieve maximum reimbursement for pharmacy charges
• Determine the appropriate billing units for every drug dispensed based on the payer’s requirements. Convert the units as prescribed and filled to the appropriate units needed to bill accurately.
• Manually validate the accuracy of billed charges on the billing edit list and/or through test claims, correct as needed.
• Submit accurate claims in a timely manner, electronically whenever possible
• Follow up on claim denials as received. Track reasons for denials and implement continual improvements to avoid denials. Appeal as appropriate and communicate with any other necessary staff to discuss any changes in process or requirements to avoid future denials.
• Communicate ongoing payment issues with the Pharmacy team so decisions can be made about future services, ABN’s, pharmacy and/or physician intervention, etc.
• Attain and maintain a comprehensive and up to date understanding of the constantly changing insurance requirements related to infusion drug therapy.
• Read all insurance company updates, newsletters, bulletins, web updates, faxes, manual updates, etc. related to infusion pharmacy
• Seek out information from insurance companies to fully understand requirements and keep up on this to capture the continual changes
• Recommend Pharmacy Benefit Managers that CHHC could contract with to expand network participation
• Develop educational documents that will be helpful to CHHC staff regarding pharmacy coverage requirements
• Train another team member who can serve as backup for basic responsibilities during absence

KNOWLEDGE, SKILLS AND ABILITIES

• Possess strong customer service skills.
• Ability to communicate effectively both verbally and in writing.
• The ability to use computers and 10 key adding machine, fax machine and copier.
• Strong mathematical skills to enable accurate medication quantity conversion for billing purposes.
• Must have the ability to work independently to effectively and efficiently perform assigned duties.

EDUCATION AND EXPERIENCE

• High school diploma or GED required.
• Minimum of three years’ experience in a pharmacy position required.
• Minimum one year experience involving pharmacy health insurance billing or authorization required.
• Knowledge of pharmaceutical products, drug names, dosage forms and pharmacy terminology required.
• Familiar with ICD-10, Per Diems, NDC and HCPC coding preferred.

CERTIFICATIONS/LICENSURE REQUIREMENTS

• Current and valid certification as a Pharmacy Technician preferred.

SPECIAL REQUIREMENTS

• Current and valid registration with the State of Nebraska preferred.

EOE/Vets/Disabled