Pharmacy Claims Reconciliation Specialist

Job Description

Job Description

Overview

The Pharmacy Claims Reconciliation Specialist is responsible for reconciling pharmacy claims and insurance payments to ensure reimbursement accuracy and resolve billing discrepancies. This role serves as a key liaison between pharmacy, finance, and operational teams by validating claim adjudication, researching payment variances, and maintaining the integrity of reimbursement data. The position supports revenue cycle activities through detailed analysis of claims, payments, denials, and reimbursement trends. The Pharmacy Claims Reconciliation Specialist also helps improve processes, ensure compliance, and support accurate financial reporting.

Responsibilities

• Reconcile pharmacy claims and insurance payments by comparing expected reimbursements to actual payments and identifying discrepancies such as underpayments, overpayments, duplicate payments, and missing payments.
• Research and analyze claim denials, payment variances, and reimbursement trends to determine root causes and recommend corrective actions.
• Coordinate with pharmacy providers and other stakeholders to investigate and resolve payment discrepancies and outstanding billing issues.
• Support revenue cycle operations through claims reconciliation, reimbursement validation, month-end activities, audit documentation, and payment file reviews.
• Generate reports on reimbursement performance, denial trends, recovery opportunities, and payment activity while identifying process improvement and automation opportunities.

Qualifications

Education

• High school diploma or equivalent required.
• Experience as a Certified Pharmacy Technician (CPhT) preferred.
• Associate degree in Healthcare Administration, Business, Accounting, Finance, Pharmacy Billing, or a related field is a plus.

Experience

• Two to four years of experience in pharmacy billing, claims processing, revenue cycle, payment posting, or insurance reconciliation.
• Experience reconciling pharmacy claims preferred.
• Experience with Medicaid, Medicare, and commercial insurance plans.
• Pharmacy claims reconciliation experience is highly desirable.

Licenses/Certifications

• None required.