Medical Billing Specialist

Pharmacy Billing Specialist Working under the direct supervision of the Pharmacy Billing Manager, the incumbent shall perform a variety of technical billing functions to support the mission of KTHFS. The incumbent will provide support to Pharmacy staff in respect to billing of prescriptions claims and services. Major duties and responsibilities include: Proactively gain knowledge to maintain a high level of industry knowledge related to the review/audit and billing of pharmacy claims for prescriptions and pharmacy services. Collaborate with and be available to pharmacy personnel for timely response and support for billing questions and needs. Build and retain positive and professional relationships with external KTHFS business partners. Use implemented and established processes to assure and maintain accurate demographic and billing information. Use implemented high-quality pre and post claims review of each prescription filled and pharmacy services to be billed. Ensure claims submission adheres to KTHFS values, mission and vision, ensuring claims are precisely and legally adjudicated and billed in effort to obtain maximum allowable reimbursement. Proactively identify opportunities to improve alternative resources for patients. Effectively work with KTHFS Patient Benefits personnel to screen and refer for potential eligibility of alternate resources. Responsible for the request and submission of pharmacy prescription prior authorization requests. Accurately and efficiently post pharmacy payments in a timely manner per protocol when requested. Use implemented process to ensure successful reconciliation of pharmacy claims working to reduce denials, receive payment and receipt of all claims. Proactively review claims history and rebill underpayments and non-payments, claims missed on insurance and/or errors found with the review/audit process. Assist the Pharmacy Staff with pharmacy audits. Communicate with tribal members, descendants, caregivers, and other health care professionals, regarding Prior Authorizations according to the Pharmacy Business Office SOP. Maintain training specific to Prior Authorizations and the detection, correction and prevention of fraud, waste and abuse in the delivery of Medicare and Medicaid benefits. Maintain other standards of annual training required for health care workers or any training required by KTHFS such as Blood Borne Pathogen, HIPAA Privacy and Security, and others as deemed necessary. Attend and participate in regular Pharmacy Billing Office and other meetings when requested by Manager. Like all employees of the Klamath Tribes, the incumbent will be called upon to accomplish other tasks that may not be directly related to this position, but are integral to the Klamath Tribes' broader functions, including but not limited to, assisting during Tribal sponsored cultural, traditional, or community events that enable the successful operation of programs and practices of The Klamath Tribes as aligned with The Klamath Tribes' Mission Statement. Some of these tasks may be scheduled outside of regular work hours, if necessary. Supervisory controls include: The immediate supervisor is the Pharmacy Billing Manager. Work is assigned in terms of goals, objectives and basic priorities. Assignments are performed according to policy and procedures set forth in the Pharmacy Billing Office SOP. New assignments will be provided in detail, as well as changes in current procedures. Major or new issues should be referred to the Pharmacy Billing Manager. Work will be reviewed for accuracy, adequacy, and timeliness. Knowledge, skills, abilities include: Possess knowledge of Oregon and federal regulations regarding pharmacy operations, rules and regulations. Possess skilled knowledge of private insurance, Medicare and Medicaid billing of pharmacy services. Ability to perform work and accomplish tasks following specific Policy and Procedures set forth in the Pharmacy SOP and priorities of the pharmacy. Must be able to communicate effectively both orally and in writing with patients, caregivers, pharmacy personnel, and other health care professionals. Possess strong public and interpersonal relationship skills. This is the ability to meet and deal with a variety of individuals by exercising tact, diplomacy, and mature judgment. Must be able to greet and deal with the public in a pleasant, courteous, and professional manner; at times in stressful situations. Must have the ability and willingness to learn new skills necessary for the obtainment/renewal of Pharmacy Technician Certification. Must possess the ability to function effectively under pressure of time and/or demands of several tasks at once. Must attain the skills and abilities to operate prescription processing computer systems. Excellent skill and ability to operate a computer and use Microsoft Office applications including Word, Excel and Outlook. Knowledge of pharmacy computer system software for billing and rebilling claims. Ability to maintain strict confidentiality of medical records and adhere to the standards for health record-keeping, HIPAA and Privacy Act requirements. Must maintain strict confidentiality of patient privacy and program information. Qualifications, experience, education include: REQUIRED to possess a High School Diploma or Equivalent. (Must submit copy of diploma or transcripts with application.) REQUIRED to possess a Certified Oregon Pharmacy Technician Licensure. (Must submit a copy of certification with application.) REQUIRED to possess a Pharmacy Technician Certification (CPhT). (Must submit a copy of certification with application.) REQUIRED to have at least ten (10) years working as an experienced Nationally Certified Pharmacy Technician. REQUIRED to be free from exclusion from providing Federal health care benefits including Medicare and Medicaid as per the Federal OIG and GSA exclusion lists. REQUIRED to receive training specifically in the detection, correction and prevention of fraud, waste and abuse in the delivery of Medicare and Medicaid benefits. Training shall be performed within 30 days of hire and at least annually thereafter REQUIRED to have excellent computer skills and word processor experience. REQUIRED to have knowledge of records management. REQUIRED to submit to annual TB skin testing and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers. REQUIRED to submit to a background and character investigation, as per Tribal policy. Following hire must immediately report to Human Resource any citation, arrest, conviction for a misdemeanor or felony crime. Preferred Qualifications: Possess a Prior Authorization Certified Specialist Certification Graduation from an accredited Pharmacy Technician training school. Applicable specialized experience billing, auditing or managing pharmacy benefits. Indian Preference: Indian and Tribal Preference will apply, as per policy. (Must submit tribal documentation with application to qualify for Indian Preference). #J-18808-Ljbffr