- Pay
- $77–95k
- Where
- Hybrid Career · Reliance Rx Specialty Pharmacy Management, LLC · Buffalo, NY (14221) · Hybrid
- Level
- Mid
FIND YOUR FUTURE
We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.
Overview
The Manager-Billing and Medical Operations is responsible for the supervision and management of all pharmacy and medical claims processing at Reliance Rx. In this role, the Manager-Billing and Medical Operations will also be responsible for the management of the billing and medical operations teams. This will include monitoring daily workflow metrics and phone metrics, as well as completing daily audits of the billing queues to ensure accurate and timely processing based on payor and internal shipping time requirements. They will assess any claims processing system upgrades and enhancements and ensure best business practices are being followed throughout the company. The Manger- Billing and Medical Operations will not only oversee pharmacy NCPDP claims, but they will also have a high level of experience and knowledge with medical claims processing and 837 set up. They will be expected to work with payors on 837 file development, 837 claim submission, timeliness of submitted claims, denials corrections and resubmission, and payment accuracy. The Billing Manager collaborates with internal departments, payors, and external stakeholders to optimize revenue cycle performance, resolve complex billing issues, maintain compliance with contractual and regulatory requirements, and drive operational excellence. This position is accountable for reimbursement accuracy, accounts receivable oversight, and the continuous improvement of billing processes and systems at Reliance Rx.
Qualifications
Bachelor’s degree required. An additional four (4) years of experience will be considered in lieu of degree.
Five (5) years of experience with third party claims billing, patient collections, or high-volume pharmacy required, to include two (2) years of specialty pharmacy, specialty infusion or related business.
Two (2) years of progressive leadership/management responsibility required.
Specialty pharmacy and copay assistance/foundation billing strongly preferred.
Medical billing and 837 claim transaction experience strongly preferred.
Strong leadership, coaching and mentoring skills with the ability to identify, address and resolve associate issues objectively and in a timely manner.
Excellent written and verbal communication skills and problem-solving skills required, including the capability to absorb new concepts and act as a role model/mentor to billing specialists.
Excellent organizational, process and time management skills required with the ability to handle multiple tasks.
Proven examples of displaying the Reliance values: Collaborative, Accessible, Results-Oriented, Empowering, and Supportive.
Essential Accountabilities
Oversee all NCPDP claims processing, medical claims submission via 837 and CMS1500, copay assistance billing, and paper claims submission when necessary.
Subject matter expert on pharmacy benefits vs medical benefits and NCPDP claims vs medical claims. Train team on the differences of each type of benefit/claim.
Serve as the subject matter expert for all billing issues and development of best billing practices. This will include reviewing escalated billing issues and performing root cause analysis on all billing discrepancies. Responsible for associate follow up, re-training, and disciplinary action when needed.
Knowledgeable on NCPDP and medical claim responses, including how to resolve rejections and read paid claim responses to identify over/under payments or other reimbursement discrepancies.
Maintain a high level of knowledge of regulatory requirements for billing (i.e. Medicare and Medicaid). Ensure payor compliance by monitoring claims and ensuring all service level agreements and shipping timelines are met.
Directly accountable for observing and reviewing billing practices at Reliance Rx;…