Closing Date: Open Until Filled (OUF)

Salary Range: $17.16 - $20.42/hour

**APPLICANT MUST HAVE A VALID, UNRESTRICTED INSURABLE DRIVERS LICENSE**

**RESUMES AND REFERENCES ARE REQUIRED**

ESSENTIAL DUTIES, FUNCTIONS AND RESPONSIBILITIES

• Analyzes, maintains, and directs the total billing operation for pharmacy point-of-sale

programs.

• Researches and follows-up on rejected claims on-line in order to ensure maximum

reimbursement to the facility. Works with the various Pharmacy Benefits Manager

help desks to fix rejects within specified time frames. This includes telephone

contacts and any steps necessary for satisfactory resolution of the claim. Documents

all information in the patient’s medical chart.

• Develops and maintains files for the tracking of billing and reimbursement. Initiates

inquiries either telephonically or by any viable means of written correspondence with

insurance companies after pre-established time frames in order to determine why

claims were rejected.

• Maintains records and files in accordance with applicable regulations and guidance.

Responsible for maintenance of general files of directives, instructions, regulations,

notices and correspondence related to Pharmacy Benefits Manager programs.

Ensures there is documentation of all action(s) taken for adequate audit trails.

Provides documentation to the insurance companies when requested for an audit.

• Maintains records of each claim billed detailing history, noting what action was taken

on each claim; and coordinates with Patient Accounts billing technicians to record the

amount collected and percentage paid; the amount resolved as invalid billings; and

the final account disposition.

• Ensures that prescriptions dispensed are entered into the system with the correct

brand name or generic name, for this information is the key to the charge generated

per visit and maintained in the accounting records.

• Requests and obtains prior authorization for various pharmaceutical products from

insurance companies. Receives and completes authorization forms providing all data

required, obtains signatures, and returns as needed for processing of collection.

• Contacts the healthcare provider for additional information when services rendered to

patient and prescription written for the patient are not clear, or when more details are

needed to complete the forms for the episode of care.

• Retrieves medical records. Researches patient records, reconstructs incorrect or

missing medical information required to prepare a valid insurance billing when data

received is incomplete.

• Provides training to patient registration staff to assure that necessary data is entered

into the registration package to identify insurance and benefits to start billing

activities into the on-line billing system. Researches new insurance registrants for

appointment history report to capture new and old billable visits. Calls insurance

carriers to obtain overwrites for old visits.

• Maintains on-line billing accounts to ensure validity of patient charges which

constitute the major portion of the hospital accounts receivable. Reimbursements

from these accounts are budgeted as a portion of the hospital operating fund.

• Maintains the interface between the various billing software and the RPMS system.

Processes payments received by pulling billing for accounts verification purposes,

making appropriate annotations and submitting to the collection clerks.

• Keeps records of Pharmacy Benefit Managers contracts and direct to Chief

Pharmacist to maintain contracts. Provide follow-up and tracking of billing

agreements including calling vendors to identify status of agreements.

• Serves as a technical resource for the pharmacy point of sale system, provides

orientation and ongoing training to personnel as directed by the Chief Pharmacist.

• Responds to third party requirements on post-payment reviews, exclusions, denials,

and appeals. Actively performs audits and medical reviews to ensure documentation

and accountability on all health insurance claims submitted for payment by conducting

random sample reviews of claims and medical records.

• Performs qualitative and quantitative analysis on the medical records to ensure it

contains proper documentation in accordance with regulations, including proper

diagnoses, physician/physician assistant original signatures(s), accurate dates of

medical care services, and that primary care providers are in compliance with

attestation and billing requirements.

• Periodically liaisons with Patient Access Representatives, Medical Support Assistants,

and Health Information Technicians to provide initial or refresher training on their

responsibilities to collect insurance information from beneficiaries at the point of

service.

• Acts as a liaison with the facility and private insurance companies in order to inform

them of billing methods and regulations.

• Explains and answers questions regarding the pharmacy POS system to patients,

physicians, pharmacists, insurance carriers, other facilities, and federal/state agencies

(i.e., Medicaid/Medicare).

• Monitors the patient data input into the RPMS/EHR system. Coordinates corrections

or changes to the patient data with the Patient Registration Office and Health

Information Services. Assures the accuracy of patient data so that correct billing

documents are produced. Locates discrepancies and determines source of error, and

takes necessary remedial action. Ensures that accounts are established for nonbeneficiaries

in RPMS and the patients are billed appropriately. Coordinates with other

work units to resolve problems pertaining to the on-line billing system/Pharmacy

Benefits Managers Program.

• Attend monthly pharmacy point of sale eLearning training provided by IHS/HQ,

register to Pharmacy billing Listserv and attend pharmacy billing point of sale office

hours when needed.

• Attend live in-person point of sale trainings conducted by other 638 facilities, Center

for Medicare & Medicaid Services (CMS), and Navajo area HIS trainings.

• Track manufacturers, NDC or lot numbers of medications not covered by insurance.

When needed, performs the task of Pharmacy Technician as listed below:

• Assists Pharmacist in filling medication orders utilizing pharmacy robotics and hand

count (i.e. ScriptPro Central); ensures appropriate medication is filled and labeling

requirements are met.

• Maintains appropriate levels of approved pre-packed medications for frequently

prescribed medications and quantities. Reconstitutes per manufacturer instructions

powder oral medications for filling.

• Compounds extemporaneous medications under the direction and supervision of a

pharmacist per compounding recipes on file in pharmacy or as approved.

• Checks in patients at pharmacy counter and directs all problems/refill denials to a

pharmacist. Takes refill requests in person at pharmacy window and off pharmacy refill

line.

• Returns medication to stock after 7 days on shelf, making notation in each patient’s

chart via RPMS and EHR.

• Provides patient education as appropriate and refers patients to Pharmacist as

necessary.

• Checks pharmacy stock see that proper levels are maintained, stock is rotated and

medications are stored properly; checks for and discards outdated drugs; and assists

with physical inventory of all medication.

• Fills automated dispensing cabinet medication orders after verification by pharmacist.

Fills and maintains pharmacy filling robotics.

• Performs related clerical work to keep accurate records, answers phones; cleans and

maintains work areas to maintain sanitary conditions in the pharmacy.

• Answers technical and patient demographic questions from information contained on

the patient profile/record; refers questions requiring professional judgment to

pharmacist.

• Performs other duties as assigned.

MANDATORY MINIMUM QUALIFICATIONS

Experience:

Three (3) years of direct work experience with a minimum of one (1) year experience related to

pharmaceutical terminology or general pharmacy operations.

Education:

High School Diploma or Equivalency (HSE).

Pharmacy Technician Certification Board (PTCB) License.

Please email degree or transcripts to Loren.Begay@fdihb.org

NAVAJO/INDIAN PREFERENCE

FDIHB and its facilities are located within the Navajo Nation and, in accordance with Navajo

Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this

Policy, applicants who meet the minimum qualifications for this position and who are enrolled

members of the Navajo Nation will be given primary preference in hiring and employment for

this position and members of other federally-recognized Indian tribes will be given secondary

preference. Other candidates will be considered only after all candidates entitled to primary or

secondary preference have been fully considered.