Pharmacy Revenue Integrity Analyst at Adventist Health

Roseville, California, United States -

Full Time

Start Date

Immediate

Expiry Date

12 Jun, 26

Salary

48.16

Posted On

14 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medication Charging, Billing Compliance, Reimbursement, CMS Regulations, HRSA Guidance, Payer Regulations, Revenue Cycle, Charge Capture, HCPCS Coding, UB-04 Claims, CDM Maintenance, 340B Compliance, Root Cause Analysis, Claim Denial Resolution, EMR Systems, Charge Automation

Industry

Hospitals and Health Care

Description

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Supports accurate and compliant medication charging, billing, and reimbursement across outpatient hospital departments such as observation units, emergency departments, outpatient surgery centers, and infusion clinics. Ensures medication-related charges are complete, accurate, compliant, and aligned with Centers for Medicare and Medicaid Services (CMS), health resources & services administration (HRSA), and payer regulations. Serves as the bridge between pharmacy operations, revenue cycle, compliance, and finance, using deep understanding of pharmacy workflows, coding, charge capture, and payer requirements to prevent revenue leakage and mitigate compliance risks. Job Requirements: Education and Work Experience: * High School Education/GED or equivalent: Preferred * Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred * Three years' of experience in hospital or health system pharmacy, revenue integrity, billing, or compliance: Required * Experience working in Epic Resolute, Cerner Revenue Cycle, or similar EMR/billing systems: Preferred Licenses/Certifications: * State Pharmacy Technician license: Required (CA, OR, &/or HI): Required * Pharmaceutical Technician Board certification: Preferred * Advanced certification (e.g., CHRI, CRCR, or 340B ACE): Preferred * State Pharmacy Technician (PTC): Required Essential Functions: * Reviews and reconciles medication charges in outpatient hospital encounters (e.g., observation, infusion, surgery, emergency department (ED)). Validates NDC-to-HCPCS mapping, billable units, and appropriate modifiers (e.g., JZ/JW) per CMS and payer guidelines. Ensures compliance with 340B, GPO, and WAC pricing policies; collaborate with 340B Program Integrity teams to maintain audit readiness. Participates in internal and external audits (CMS, HRSA, internal compliance, or payer audits). * Identifies and corrects charge capture errors prior to billing to ensure clean claims submission. Monitors UB-04 claim accuracy for outpatient medication billing and ensure HCPCS and revenue codes align with clinical documentation. Collaborates with revenue integrity, HIM, and pharmacy to maintain compliant and optimized CDM (Charge Description Master)/ Medication Record Master File (ERX) entries for medications. * Stays current on CMS outpatient prospective payment system (OPPS) updates, HRSA guidance, NDC-to-HCPCS quarterly crosswalks, and payer-specific requirements. Supports resolution of claim denials related to outpatient drug charges, waste modifiers, medical necessity, or coding errors. Performs root cause analysis of denied or underpaid medication claims and recommend preventive actions. * Partners with revenue cycle teams to adjust, rebill, or appeal denied medication claims when appropriate. Works with pharmacy procurement, buyers, and compounding teams to understand medication usage patterns, vial utilization, and potential billing impacts. Serves as a subject matter expert for medication charge capture during EMR upgrades, build validation, and workflow changes. * Assists in the design and maintenance of charge automation rules and EMR charge capture mapping (Epic, Cerner, etc.). Educates pharmacy and revenue cycle staff on charge accuracy, 340B compliance, and billing best practices. Tracks and reports charge correction trends, denial root causes, and reimbursement impact. Identifies systemic issues and recommend process improvements to reduce recurring errors. * Performs other job-related duties as assigned. Organizational Requirements: Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

Responsibilities

This role supports accurate and compliant medication charging, billing, and reimbursement across various outpatient hospital departments by ensuring charges are complete and aligned with CMS, HRSA, and payer regulations. Responsibilities include reviewing and reconciling medication charges, validating coding, maintaining compliance with pricing policies, and collaborating with revenue cycle and pharmacy teams to optimize charge capture.