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Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview

The Pharmacy Billing Senior Specialist independently performs advanced analysis of pharmacy billing and claims data to identify discrepancies, compliance gaps, and emerging reimbursement risks. Applies advanced analytical techniques to detect systemic issues and collaborates with cross-functional partners to develop practical, data-driven solutions. Contributes to the design and enhancement of scalable audit and monitoring frameworks that extend beyond routine compliance checks and support enterprise-wide billing accuracy. Supports complex Pharmacy Revenue Cycle functions, including reimbursement optimization, denial trend evaluation, and resolution of escalated billing scenarios under managerial direction.

Locations

Stanford Health Care

What you will do

+ Independently reviews and analyzes complex Pharmacy billing and claims data to identify discrepancies, compliance issues, and reimbursement risks across multiple payer types.

+ Applies advanced analytical methods to detect trends, forecast potential issues, and support data-driven decision-making for Pharmacy Revenue Cycle workflows.

+ Contributes to the development and refinement of scalable audit frameworks and monitoring processes, ensuring consistent enterprise-wide review of charges and claims on a regular basis.

+ Works proactively and independently to identify billing or workflow issues, escalate appropriately, and drive timely resolution under managerial guidance.

+ Investigates and resolves complex billing issues, collaborating with Revenue Cycle, Compliance, and TDS to implement corrective actions and improve process reliability.

+ Supports denial resolution by performing root-cause analysis and contributing to targeted denial prevention strategies across pharmacy billing workflows.

+ Provides advanced subject-matter expertise to pharmacy staff and stakeholders regarding billing compliance, coding guidelines, and payer requirements. Research, interpret, and apply complex payer and regulatory guidance to resolve escalated issues and support Pharmacy Revenue Cycle Manager in developing consistent practices.

+ Collaborates with cross-functional teams to improve charge capture workflows, documentation practices, and reimbursement processes.

+ Assists in enhancing and maintaining pharmacy billing dashboards and performance metrics, contributing insights for performance improvement.

+ Participates in or leads operational initiatives aimed at improving accuracy, efficiency, and compliance of the Pharmacy Revenue Cycle.

+ Develop, analyze and maintain key performance indicator (KPI) data for Pharmacy Billing Dashboard. Lead enhancement to dashboard functionality, ensure data accuracy and integrity, and translate findings into actionable insights for performance improvement across pharmacy revenue cycle operations.

+ Lead or provide support for ad hoc projects or departmental initiatives, including participation in committees as assigned.

+ Lead communication and education efforts for Clinic Administration, Clinic Managers and clinic staff on complex pharmacy-related matters, including regulatory and compliance updates, relevant FDA drug recalls, and drug information, specialty programs, and investigational studies. Develop and implement standardized education and communication tools to ensure consistent adherence to evolving regulations and alignment with SHC policies.

+ Refine and standardize Pharmacy Technician workflows and SOPs relating to billing in collaboration with pharmacists, technicians, and leadership. Identify process gaps and recommend practical improvements to enhance consistency, efficiency, and compliance across assigned areas.

+ Develop, update, and maintain SOP for pharmacy billing specialist workflow under the direction of Pharmacy Revenue Cycle Manager. Ensure procedural accuracy, alignment with compliance standards, and practical applicability across pharmacy billing operations.

Education Qualifications

+ PharmD Degree from an accredited college/university required

Experience Qualifications

+ Seven (7) years of progressively responsible and directly related work experience required

Required Knowledge, Skills and Abilities

+ Knowledge of healthcare financial operations.

+ Knowledge of healthcare regulations and policies affecting pharmacy billing, reimbursement, and financial compliance at both federal and local levels.

+ Knowledge of other relevant regulatory guidelines (e.g., CMS, 340B, FDA).

+ Knowledge of the Pharmacy Revenue Cycle, including charge capture, claim submission, reimbursement methodologies, and denial management.

+ Knowledge of and demonstrated proficiency in the use of office and data analysis tools (Word, Excel, PowerPoint, Visio, Access, Project and Outlook).

+ Knowledge of project management process and systems.

+ Knowledge of theories, principles, practices and techniques of personnel management, including selecting, training, directing, evaluating, and supervising employees.

+ Excellent attention to detail, organizational skills, and the ability to manage multiple priorities independently.

+ Ability to interpret complex financial or billing datasets.

+ Ability to implement large-scale initiative that requires cross-functional coordination

+ Ability to mediate and resolve complex problems and issues.

+ Ability to develop financial budgets and manage expenses.

+ Ability to develop long-range business plans and strategies.

+ Ability to develop and maintain productive and cooperative work relationships at all levels both within and outside the organization.

+ Ability to communicate effectively at all organization levels and in situations requiring instructing, persuading, negotiating, conflict resolution, consulting and advising as well as prepare clear, comprehensive written and oral reports and materials.

+ Ability to effectively manage and promote staff development.

+ Ability to articulate strategic planning.

+ Ability to lead process excellence team to effectively improve operational efficiencies.

+ Ability to manage financial performance process including accuracy of submission.

+ Demonstrated skills in analytical assessment, oral and written communication.

+ Strong communication skills and ability to promote and maintain interpersonal relationships.

Licenses and Certifications

+ RPH - Registered Pharmacist required

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

_Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery._

_You will do this by executing against our three experience pillars, from the patient and family’s perspective:_

+ Know Me: Anticipate my needs and status to deliver effective care

+ Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

+ Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in** **all of** **its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $79.21 - $104.97 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow.

As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.

Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .