Reimbursement Spec Pharmacy

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

4/1/2022

Entity:

Wisconsin

Job Code:

440076

Job Title:

Reimbursement Spec Pharmacy

Exemption Status:

Non-Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The Reimbursement Specialist Pharmacy is responsible for a portfolio of accounts receivable and oversees the billing cycle from charge review, claims submission and follow-up.  The employee is engaged in pro-active and independent collection of outstanding balances for specially handled UW Health pharmacy accounts.

The position requires advanced knowledge of various program billing requirements as well as federal research billing rules, Medicare and Medicaid. The incumbent actively participates in both external third-party audits and in internal audits and quality improvement initiatives, maintains documentation of current workflows, assists with special projects, and works closely with Transplant and Infectious Disease teams, UW Health fiscal teams, and with Pharmacy Department Leadership and Prior Authorization teams. The employee performs complex patient account follow-up activities and actively participates in quality improvement initiatives to improve accounts receivable processes.  The Reimbursement Specialist Pharmacy is also responsible for the accurate and timely processing of appeals to various pertinent payers or programs.  

The Reimbursement Specialist will serve as the technical expert for complex workflows. The specialist is responsible for handling charge review edits, claim edits and preparation, insurance follow-up, denial resolution, and necessary follow-up to ensure accurate payment. 

MAJOR RESPONSIBILITIES

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Maintain a portfolio of accounts receivable for Pharmacy. Follow accounts through the Pharmacy revenue cycle, including but not limited to: verifying patient coverage information, updating registration, completing charge review, claim edits and claim submissions, and following up with third party payers and patients to facilitate prompt resolution of outstanding account balances.

•

Communicate with Revenue Cycle teams, payors and others to resolve account problems; participate in meetings as needed to address payor concerns

•

Evaluate the payment status of outstanding third-party claims and resolve impediments to payment by providing information such as medical records, itemization of charges, information regarding other insurance benefits, and explanation of charges.

•

Review and validate adjustments to accounts in the insurance portfolio based on insurance reimbursement, coverage, contracts and services provided.

•

Review charges to ensure filing to correct guarantor (e.g. work comp vs. personal/family)

•

Conduct collections calls to patients with outstanding balances. Negotiate full payment from patients and/or assist patients in setting up a payment plan. Provide education to patients on UW Health’s financial assistance policy and application process. Direct patients to the appropriate resources as necessary (e.g. Financial Counseling, Patient Relations)

•

Receive, document, and respond to all patient correspondence in a prompt and courteous manner; accurately document all actions take to reconcile outstanding balances

•

Assist patients in coordinating appeal processes with their insurance company

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Review self-pay undistributed and credit balance accounts and provide refunds to patients as necessary

•

Accurately post EFT, cash and checks made payable to UW Health to the Billing System. Ensure that all transactions are completed within the appropriate guidelines, policies and regulations, typically the same day received. Process electronic remittance files, payor work queues, and generate payment reports to balance.

•

Communicate with UW Health staff, insurance companies, financial institution and third-party payors to resolve

•

issues related to proper posting of payments.

•

Complete work on special projects, queries and reports as assigned

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.

X

Non-Clinical

JOB REQUIREMENTS

High School Diploma

or equivalent

Required

Associate's Degree

in Business, Finance, Health Information Management, or related field

Preferred

2 years

of experience in a healthcare revenue cycle or clinic operations role

Required

1 year

of pharmacy experience in a retail pharmacy setting

Preferred

Epic experience

Preferred

•

In-depth understanding of Pharmacy billing policies and procedures including NCPDP D.0 standards

•

Proficiency in spreadsheet and database software

•

Advanced analytic ability

•

Ability to make good judgments in demanding situations

•

Effective communication skills

•

Ability to logically and accurately organize details

•

Ability to manage multiple tasks with ease and efficiency

•

Ability to work independently and be result oriented

•

Positive, can-do attitude coupled with a sense of urgency

•

Effective interpersonal skills, including the ability to promote teamwork

•

Ability to ensure a high level of customer satisfaction including employees, patients, visitors, faculty, referring physicians and external stakeholders

•

Ability to use various computer applications including EPIC, Microsoft Office, etc.

•

Basic math skills and knowledge of general accounting principles

•

Knowledge of medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, UCF, 1500)

•

Maintain confidentiality of sensitive information

•

Knowledge of local, state and federal healthcare regulations

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

☐

Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☐

Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

☐

Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

☐

Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

☐

Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.