Pharmacy Billing Technician

Pharmacy Billing Technician

Primary responsibilities involve performing a full range of pharmaceutical billing technician duties including the submission of properly executed pharmaceutical claims on a timely basis to third party payers and responsible parties by utilizing the RPMS Pharmacy Point of Sale system; rebilling or correcting billing of accounts previously submitted. Additional responsibilities include various clerical tasks and assisting the billing staff with any questions on unpaid pharmacy claims.

Specific duties include, but are not limited to:

• Analyzes, maintains, and directs the operations for the pharmacy point-of-sale program.
• Approves, edits and overrides pharmacy claims for the OHC in RPMS POS system.
• Researches, enters, and runs eligibility on new pharmacy insurance plans to RPMS using different insurance portals.
• Researches and verifies patient insurance for all pharmacy insurances when encountering errors during edit of claims in RPMS.
• Coordinates benefits, verifies data and gives appropriate information to the PBC/PSR staff.
• Completes insurance data for patient claims; processes, researches and corrects accounts; verifies diagnosis and authorization codes; identifies liability and guarantors; interprets Explanation of Benefits (EOBs); and analyzes billing components.

• Submits prior authorizations for all prescriptions requiring a prior authorization in the Pharmacy using Cover My Meds.
• Reviews all denied claims to determine if a claim was denied incorrectly.
• Answers questions from relatives, staff, and insurance companies.
• Runs, maintains, and monitors POS reports including STRANDED, MISS OPPORTUNITY, DUPE CLAIM REPORT, CORRUPTED REPORT monthly, notifying the business office manager of any trends or problems, notifies technicians of errors, and contacts third party providers when necessary.
• Runs a Before and After back bill report which generates rejected claims to be worked weekly.
• Runs a rejected claims report to be worked daily.
• Maintains accuracy in RPMS NDC's and cost and removes any inactive NDC.
• Utilizes ScriptPro regularly to verify accurate NDC, dispense, mail, and research information for audits to provide proof of dispense.
• Assists Pharmacy Supervisors in the maintenance of the RPMS Pharmacy Drug Files in the computer system for billing purposes, such as updating NDC numbers and "re-matching" drugs to the National Drug File (NDF) when necessary.
• Handles all pharmacy audits including individual and desktop, maintains record keeping for 7 years This is to include researching, gathering information, creating reports Conducting internal audits to mitigate the risk of fraud.
• Answers all correspondence requesting information on provider or relative.
• Notifies supervisor of all claims deemed unbillable along with reason(s) on a daily basis.
• Serves as a POS technical resource, provides orientation, and provides ongoing training and education to billing staff.
• Works closely with pharmacists to collaborate on formularies.
• Maintains a list of uninsured relatives who routinely receive high dollar medications. This is shared with PBC to capture revenue if insurance changes.
• Maintains a list of high dollar medications that South Dakota Medicaid allows a resubmission above the all inclusive rate.
• Maintains a list with the pharmacist of relatives who have insurance that fill at outside pharmacies to prevent duplicate fills and potential adverse reactions.

Additional duties:

• Attends monthly POS webinars to remain knowledgeable, ask questions, or keep up on new patches.
• Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
• Performs related duties as assigned.
• Performs the core responsibilities of the position accurately, timely, and in accordance with established standards.
• Maintains regular and reliable attendance consistent with the position's schedule and operational needs.
• Communicates effectively with internal and external stakeholders as required by the role.
• Adheres to all applicable policies, procedures, and regulatory requirements.
• Utilizes required systems, tools, and technology necessary to perform the job.

Minimum Qualifications

• Completion of a formal training program or an associate's degree and one (1) year relevant experience; or, a high school diploma or GED and three (3) years of relevant experience.

The GPTCHB is a tribal organization which follows tribal preference laws. It is our policy to give preference to qualified Indian/Tribal candidates overqualified non-native candidates in hiring decisions, if all other qualifications are equal.

Employment is contingent upon the outcome of all required criminal background checks and pre-employment drug screen.

Compliance with our Employee Health Procedure is a condition of employment. You are required to agree that you will comply with all job-related employee health screening and immunizations prior to your first day of employment. Jobs require that you have documentation that you have completed the following immunizations prior to your first day of employment: MMR (Measles, Mumps and Rubella, Varicella (Chicken Pox), Hepatitis B, Influenza, T-dap (Tetanus - Diphtheria - Pertussis), and COVID-19 vaccination is required.

This position requires the ability to perform the essential functions of the job, with or without reasonable accommodation. Physical demands and work environment may include:

• Primarily sedentary work is performed in an office or administrative setting.
• Requires the ability to sit for extended periods and regularly use standard office equipment such as a computer, keyboard, telephone, and copier.
• Occasional standing, walking, bending, and reaching may be required.
• Ability to lift and carry office materials or supplies up to 25 pounds occasionally.
• Requires manual dexterity and visual acuity for computer use and document review.
• Must be able to read, write, speak, and hear.
• Work is performed primarily in an indoor office or administrative environment.
• The environment involves everyday risks or discomforts that require normal safety precautions typical of office settings, including proper use of office equipment and awareness of trips, falls, and fire regulations.
• The work area is adequately lighted, heated, and ventilated.
• Minimal exposure to hazardous conditions; no routine exposure to clinical, field, or high risk environments.
• Occasional attendance at meetings, training sessions, or events may require travel within the organization's facilities.

The employee must comply with all organizational policies, procedures, and applicable laws and regulations. This position is subject to Native Preference, background checks, health requirements, and other applicable organizational standards.