Pharmacy Billing Specialist

Job Summary:


The Pharmacy Billing Specialist will be responsible for oversight and coordination of pharmacy reimbursement operations, third-party billing, audits, and compliance activities for the ambulatory pharmacy services. This role ensures accurate and timely billing, supports audit readiness and response, maintains compliance with federal and state regulations, and leads process improvement initiatives related to pharmacy revenue cycle performance. The specialist identifies opportunities for revenue integrity improvements, reduces denials, and mitigates compliance risks related to federal, state, and commercial payers. The Pharmacy Revenue Cycle and Audit Specialist exemplifies the mission, vision and values, applies highly reliable pharmacy revenue cycle standards, and demonstrates teamwork through daily actions. The ideal candidate will drive pharmacy revenue cycle innovations, collaborate with cross-functional teams, and adapt to evolving healthcare standards and technologies in a dynamic, integrated health system environment.

Job Responsibilities:

• Performs day-to-day functions of pharmacy revenue cycle, prioritizing work in coordination with pharmacy leadership. Collaborate with pharmacy operations, finance, and billing teams to standardize processes and resolve medication-related claim issues.
• Supports standardization and works to optimize the performance of insurance benefit verification, prior authorization preparation/submission, and appeals for pharmacy claims workflows.
• Process and submit accurate claims for medications, ensuring proper use of HCPCS/CPT codes, revenue codes, billable units, modifiers, and multipliers.
• Manage claim rejections, denials, and underpayments; investigate root causes and implement corrective actions to maximize reimbursements.
• Oversee charge capture, billing workflows, and collections to optimize cash flow and minimize outstanding accounts receivable.
• Ensure timely and accurate submission of primary and secondary prescription claims.
• Manage all third-party payor audits, including timely preparation, coordination, reporting, and escalation for appeal.
• Conducts scheduled and ad-hoc audits of pharmacy billing, charging, and collection practices to ensure alignment with payer contracts, Medicare/Medicaid guidelines, HIPAA, and other federal/state regulations at the direction of the Manager.
• Review claims, remittance advices, and documentation for accuracy, completeness, and compliance (including 340B program auditing where applicable).
• Prepare audit reports, findings, and recommendations; track corrective action plans and monitor ongoing compliance.
• Support external audits or payer reviews by compiling documentation and responding to requests in a timely manner.
• Monitor compliance with federal, state, and payor-specific billing requirements.
• Monitors evolving payer policies, regulatory changes (e.g., Medicare Part D, specialty pharmacy requirements), and best practices in pharmacy revenue cycle.
• Develop and maintain training modules related to billing, audits, and compliance.
• Serve as liaison between pharmacy, patients, payors, and internal stakeholders.
• Identify and implement revenue cycle and workflow improvements.
• Monitors key performance metrics (e.g., denial rates, first-pass claim acceptance, days in accounts receivable) using tools like Excel or revenue cycle software.
• Analyze trends in denials, underpayments, or audit findings; recommend policy/procedure updates to enhance revenue capture and reduce risks.
• Serve as a subject matter expert on pharmacy billing, charging, and compliance topics; provide education and training to pharmacy staff, billing teams, and other stakeholders.
• Participate in financial analyses for proposed changes to the pharmacy charge description master (CDM) or formulary impacts.

Required Job Qualifications:

• Associate degree required.

• 5 years' pharmacy experience in a progressive, complex healthcare environment
• Hands-on experience with claims processing, denial management, prior authorizations, and compliance audits.
• Experience with 340B programs, HCPCS/CPT coding, and payer-specific guidelines (Medicare, Medicaid, commercial insurers).

Preferred Job Qualifications:

• Bachelor's degree preferred
• Minimum two (2) years of progressively responsible pharmacy reimbursement or billing experience.

• Experience with Medicare, Medicaid, and third-party payor billing.

• Strong analytical, organizational, and communication skills.

Physical Demands:

• Prolonged periods of standing, walking, or sitting, with occasional computer work for extended durations.
• May require lifting to 20 pounds (e.g., inventory handling).
• Work in a high-pressure, fast-paced environment with potential for on-call responsibilities to address urgent operational or clinical issues.