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Reimbursement Analyst – Home Infusion Pharmacy

Job Code: 2907

Job Summary

Works as a team member to accomplish goals of the Munson Healthcare Home Infusion Pharmacy, as well as organizational goals. Responsibilities include accurate referral review and insurance verification along with Co-Pay assistance as needed for patients qualifying for Home Infusion Pharmacy services. Works closely with providers and nurses to ensure prior authorizations are completed and received so that reimbursement will be achieved. Has a strong working relationship with multi-disciplinary teams to ensure effective implementation, maintenance, and compliance of the Home Infusion Pharmacy reimbursement processes promotes and supports MHC’s True North goals.

Education and Experience

EDUCATION/EXPERIENCE

Min/Preferred

Education Level

and/or

Years of Experience

Comments

Required

High School or GED

2 Year / Associate Degree

and

2

Associates degree in Business Administration, Accounting or healthcare related field or equivalent work-related experience will be considered.

Preferred

Experience working in the health care field especially in Revenue cycle, Home Infusion Therapy, Third Party Contracting, and Reimbursement highly desired.

An understanding of insurance rules and guidelines desired.

Experience pharmacy billing a plus.

CERTIFICATION, LICENSURE, REGISTRATION

Min/Preferred

Certification, Licensure, Registration

Comments

Minimum

OTHER REQUIREMENTS

Key Competencies and Skills

• Strong communication skills, both written and verbal.

• Exceptional organizational skills with ability to independently recognize and analyze problems, develop and implement solutions, meet tight deadlines and handle diverse responsibilities.

• Must be proficient in Excel, Word, various EMRs and billing software, and adaptable to new software.

• This position may be performed remotely after experience is gained and demonstrated independence and dependability.

• Proficient in Pharmaceutical and billing calculations

• Understanding of ICD-10, HCPCs and CPT coding

Essential Duties

SPECIFIC DUTIES – REIMBURSEMENT ANALYST

1. Participates in all the functions and processes that support the Pharmacy Home Infusion revenue cycle that may include the following:

a) Registration

b) Insurance verification

c) Charge entry

d) CMNs

e) Delivery

f) Assignment of Benefits

g) Advance Beneficiary Notice

h) Billing

i) Collections

j) Process design

k) Compliance

l) Reporting

m) Charge master maintenance

2. Perform verification & prior authorization duties.

3. Communicate with Hospital Case Managers to assist with patient discharges.

4. Maintains expertise in reimbursement and compliance standards for insurance payers.

5. Oversee, inspect, and maintain medical charts for all required documentation relative to payers’ requirements

6. Reviews and resolve discrepancies on claims, investigates, communicates and educates findings.

7. Monitors monthly accounts receivable for denials. Investigates denials and works with insurance companies on resolution in a timely manner. Communicates and educates results with home infusion team.

8. Audit accuracy of insurance payments and resolve discrepancies to insure optimal payment.

9. Assist patients regarding insurance benefits and/or patient pay balances

10. Insurance claims follow up (i.e.: denied claims and/or unpaid claims over 45 days).

11. Problem solve and educate Home Infusion Clinical team regarding insurance guidelines for compliance.

12. Answers billing questions from patients and caregivers

13. Assists with monitoring and updating chargemaster for drug and supply costs/charges.

14. Performs other duties and responsibilities as assigned.

15. Assists in maintaining patient records

16. Performs other duties as assigned.

Work Environment and Physical Requirements

PHYSICAL DEMANDS

• Frequent/continuous sitting with occasional, intermittent standing/walking.

• Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.

• Occasional/intermittent reaching at or above shoulder level.

• Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting and climbing.

• Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.

• Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.

WORK ENVIRONMENT

• Primarily an inside building/office environment, well lighted and ventilated, which may consist of multiple treatment and/or work sites.

• Fast and continuous work pace with variable workload.

• Frequent contact with staff and public under a variety of circumstances. Requires ability to communicate clearly (in English) verbally and in writing for effective communication with other staff members, physicians, vendors, community members, patients and patient families, employees and applicants of all socio-economic levels from a diverse cultural and ethnic population.

• Answers phones

Reports To

• Works under the general supervision of the Clinical Coordinator and Manager of Home Infusion Pharmacy.

• Must maintain a professional working relationship with all staff.

• Must maintain a professional working relationship with Munson affiliates.

Organizational Expectations

• Models Munson Healthcare’s Purpose – We Improve Lives

• Embraces and supports the Munson Healthcare Alignment Framework including our Purpose, Mission, Vision, Values, True North Goals, Strategic Vision and Goals, and Operating System.

• Promotes personal and patient safety.

• Uses effective customer service/interpersonal skills at all times.