QUALIFICATIONS & SKILLS

• Strong knowledge of pharmacy and medical billing terminology.
• Proficiency with Medicare, third-party payers, and regulatory billing codes.
• Excellent analytical, audit, and reconciliation skills.
• Ability to interpret payer contracts, drug orders, and electronic billing systems.
• Effective communicator, both written and verbal, with strong collaboration abilities.

• Review and resolve rejected claims daily, taking necessary actions to resubmit or appeal.
• Investigate and follow up on unpaid or underpaid pharmacy claims via phone and written communication.
• Apply knowledge of payer contracts and state/federal regulations to validate reimbursement accuracy.
• Monitor claim rejections to identify trends, system gaps, and opportunities for edit enhancements.
• Serve as a subject matter expert in pharmacy billing, payer reimbursement, and claims resolution.
• Read and interpret prescription drug orders and billing documentation accurately.
• Assess claims for compliance with Medicare, Medicaid, and third-party billing requirements.
• Collaborate with cross-functional teams to reduce denials and minimize avoidable write-offs.
• Apply analytical skills to track performance metrics, trends, and improvement opportunities.
• Respond to inquiries regarding billing compliance, coding discrepancies, and payer policy changes.
• Conduct timely follow-ups on account balances, adhering to a 45-day protocol post-service.
• Communicate findings and solutions clearly through meetings, email, reports, and presentations.
• Uphold the hospital’s Core Values in daily work and decision-making.