To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Provides a wide variety of billing, collections and business management services associated with the daily billing operation of the Specialty Pharmacy business to provide accurate and efficient Medicare Part B Billing to achieve our Quality and Financial goals. Responsible for Pharmacy Insurance data entry and verification of Medicare Part B, Commercial Insurance, and Medicaid. Must have knowledge of processing Insurance claims and be able to handle any incoming inquires form insurance providers, health system providers an/or patients.
- 1. Accurately audits/reviews Medicare Part B billing and maintains documentation/information needed for claims in our epic specialty and Willow ambulatory module systems. Ensures appropriate billing by liaisons of primary and secondary payor sources. Reviews CMS paperwork and prescriptions for accuracy and completeness prior to medications being filled and delivered, whenever possible, in order to ensure proper adjudication and compliance
- 2. Audits charges and confirms payment on Medicare Part B claims. Corrects discrepant claims and re-files as needed to ensure proper payment. Develops and implements processes to seamlessly track claims submitted on a daily basis. Establishes and maintains appropriate documentation needed to receive payment from CMS, including delivery sheets, signatures, proof of delivery, and fill documentation. Gathers information and documentation for audits/claims/payments from Omnisys, Noridian, and other vendors/portals, to audit the payments from Medicare, Medicaid, and all supplemental and secondary payers to ensure reconciliation of payments from payer sources for proper and full payment. Works with secondary payer sources to ensure they were notified by Medicare of their payment responsibilities. Assist in the communication process of resolving reimbursement or denial issues with contracted payers. Responsible for securing reimbursement and performing actions such as re -bills, debit & credit, adjustments, refunds, and claims corrections. Monitors and maintains fee schedule used to reconcile payments on a quarterly basis. Works closely with Finance team on a weekly and ongoing basis to ensure all accounts are paid in full and up to date. Reviews Explanation of Benefit (EOB) forms, prepares, tracks, and maintains invoiced billing of Medicare Part B patients who owe the pharmacy for their medications. Follows departmental procedures for Medicare Part B billing. Utilizes Absolute Accounts receivable and finance team as needed for billing purposes. Communicates with supervisor of business operations on any accounts that are deemed uncollectable by CMS and YNHH standards.
- 3. Communicates with patients in a friendly and welcoming manner. Answers and resolves all incoming calls regarding med b billing. Updates demographic information such as address, birthdate, insurance information and allergies when needed. Responsible for finding a patients insurance information if the patient is unable to provide. Consistently uses CHAMP behaviors and the YNHH Standards of Professional Behavior when interacting with others.
- 4. Demonstrates sufficient knowledge of current Medicare Part B claims, insurance company requirements, and third party regulations related to Medicare. Ensures compliance with all HIPPA policies specifically relating to patient confidentiality and release of information. Organizes and performs routine in-services, of the basic medicare part b processes and updates, to staff, and ancillary staff, to keep them up to date with the current state of our medicare part b practices.
- 5. Develops, manages, and maintains various electronic documents used to organize and track projects, reports, and outcomes. Maintains an up to date list of COBA codes, and other pertinent medicare part b related information. Assists medicare b analyst II?s and III?s, as well as the supervisor of business operations, with projects and tasks related to medicare part b when needed.
- 6. Interfaces with Omnisys and other 3rd party vendors, and understands their functionality and purpose. Responds to all billing audit requests and coordinates all related activities from point of request through the appeals process. Manages incoming and outgoing communication from all CMS governmental auditing contractors by serving as the primary point of contact for all audit requests, results, and appeals. Researches to stay informed of all audit activities and requirements at the national and local level and provides updates to operational leaders and senior management of any Medicare changes in medication coverage, accepted diagnosis codes, and policies and procedures. Monitors the CMS, Noridian, Change Healthcare, and Absolute Accounts Receivable websites for any updates to ensure that our accounts are compliant with Federal and State requirements.
- 7. Performs other tasks/projects as directed by supervisor of business development or other member of MCP pharmacy management. Tasks/projects may or may not be directly related to the medicare part b department.
High School Diploma or equivalent required.
Retail Pharmacy Technician experience preferred. A minimum of 3 years work experience in the healthcare field specifically in medical billing and collections preferred.
Excellent administrative and organizational skills. Strong accurate attention to billing and collections details. Must have excellent communication skills and the ability to prioritize and multitask/change tasks frequently and quickly. Knowledge of drug products preferred. Must have working knowledge of Medicare, Medicaid, third party insurance company guidelines and regulations. Strong computer skills with EMR experience a plus. Must have patient management expertise.
Office position, located in Hamden, full time weekday position with some Saturdays required.