Description

JOB SUMMARY

The Operations and Clinical Claims Specialist is responsible for supporting the Revenue Cycle Management (RCM) operations, onboarding of client programs and process improvement while collaborating on strategic projects.

ESSENTIAL DUTIES & RESPONSIBILITIES

Revenue Cycle Management - Clinical Claims

• Support all aspects of revenue cycle management (RCM) pertaining to pharmacy services provided as a medical benefit (claim posting and submission, payment posting and claim reconciliation, denials management, repot generation).
• Understands and can speak to billing and reimbursement protocols, set forth by HIPAA and other government compliance authorities with whom pharmacy clients are contracted.
  Responsible for special program implementation requiring pharmacy clinical billing.

Operational Analysis and Process Implementation

• Analyze organizational processes and data as required.
• Identify areas for process improvement to improve quality, productivity, and efficiency.
• Implement process improvements based on the defined requirements and objectives.
• Synthesize data and feedback from users, clients, management, and data reporting tools to deliver progress reports, and enhancement evaluations
• Assist with ad-hoc projects as required.

Subject matter expert on all product offerings

• Acquire a high-level competency in full offering of Company’s software products or services.
• Possess advanced knowledge and understanding of healthcare industry and all assigned products.

Qualifications

KNOWLEDGE & REQUIREMENTS

What is expected of you and others at this level

• Applies comprehensive knowledge and a thorough understanding of concepts, principles, and technical capabilities to perform varied tasks and projects
• May contribute to the development of policies and procedures
• Develops technical solutions to a wide range of difficult problems
• Completes work; independently receives general guidance on new projects
• Work reviewed for purpose of meeting objectives

Preferred Qualifications

• Minimum of 2 years’ experience in revenue cycle management within a healthcare clinic or hospital
• Minimum of 2 years’ experience with practice management and electronic medical records (EMR) application integrations, or training
• Minimum of 2 years’ experience with EDI clearinghouses such as Availity or CHANGE Healthcare, and direct EDI connection to payers
• Thorough understanding of EDI concepts, role of clearinghouse and ANSI 837P and 835 formats
• Minimum of 2 years’ experience with provider credentialing either direct with payer or CAQH
• Project management experience preferred

EDUCATION & EXPERIENCE REQUIREMENTS

• Minimum years of work experience: 2 years in healthcare industry preferably in revenue cycle management
• Minimum level of education or education/experience: Bachelors Degree or equivalent experience

PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Frequent sitting in stationary position at a desk
• Occasional standing, walking, stooping, kneeling, squatting, and climbing stairs
• Occasional twisting of body
• Occasional reaching by extending hands and arms in any direction
• Occasional lifting, pulling, or pushing