Pharmacy Revenue Recovery Lead

The Pharmacy Services Lead Revenue Analyst provides advanced expertise responsible for supporting the day-to-day operational execution of pharmacy revenue integrity functions across the delivery system. This role serves as a subject matter expert and escalation resource, leading complex analyses, resolving reimbursement issues, and guiding team workflow to ensure accuracy and optimization of pharmacy financial performance.

This position plays a critical role in enabling the Director to focus on strategic priorities by providing support to teammates on claim discrepancies, managing escalations, and driving advanced problem solving. The Lead supports pharmacy services financial performance by overseeing high-impact reimbursement analyses, identifying payment discrepancies, and driving initiatives that enhance revenue capture.

Essential Functions:

Day-to-Day Decision-Making

• Operates with a high degree of independence and ability to lead teammates in managing day-to-day issue and analytical outcomes
• Make decisions on day-to-day workflows, issue resolution approaches, and revenue recovery
• Influences team direction and outcomes without direct supervisory authority

Escalation Management & Complex Problem Solving

• Act as the primary escalation point for complex reimbursement issues, claim discrepancies, and payer-related challenges
• Lead root cause analysis for payment variances, contract misalignment, and system or process breakdowns
• Develop and recommend actionable solutions to resolve high-impact financial and operational issues
• Support and guide team members through ambiguous or complex claims validation
• Partner with leadership and cross-functional stakeholders to resolve escalated concerns efficiently and timely
• Monitor team workflows including reporting, reconciliation, and contract tracking to ensure operational continuity and deadlines are met

Advanced Financial Analysis & Revenue Integrity Strategic Support

• Lead analysis of payment variances, and identifying revenue and cost trends
• Oversee tracking of contract performance against financial projections and expected reimbursement
• Lead team in performing timely updates and accuracy of third-party payer fee schedules, charge masters, and payment methodologies
• Review charge levels against payer contracts and validate reimbursement accuracy
• Guide and review claims reconciliation activities, ensuring discrepancies are identified, investigated, and resolved
• Lead revenue capture analysis, validating reimbursement and identifying opportunities for optimization
• Provide advanced, actionable insights and recommendations based on trend analysis and financial modeling
• Identify inefficiencies or gaps in processes and recommend improvements to enhance revenue capture and operational effectiveness
• Support development and implementation of new tools, automation, reporting approaches, and analytics frameworks
• Provide insights and operational input to support strategic initiatives led by the Director

Coaching, Guidance & Knowledge Sharing

• Provide informal coaching, technical guidance, and mentorship to team members to strengthen analytical capabilities
• Assist with onboarding and training of new staff, including development of tools, policies and procedures, and best practices
• Share expertise on payer contracts, reimbursement methodologies, and revenue integrity systems
• Offer real-time feedback to improve quality and consistency of work
• Serve as a role model for analytical rigor, problem solving, and collaboration
• Provide industry expertise to Solutions partners including meetings to provide insight and feedback on proposed solutions and products

Research & Subject Matter Expertise

• Maintain advanced knowledge of pharmacy reimbursement, payer contract structures, and claims adjudication processes
• Act as primary team resource for payer portals, payer and industry updates
• Develop deep expertise in revenue integrity systems and databases
• Support and sometimes lead projects related to revenue integrity improvements, automation and payer optimization
• Participate in internal and external stakeholder meetings as a representative of the team

Analysis

• Provide day-to-day coordination and guidance to Revenue Analysts and team members to ensure timely and accurate completion of revenue integrity activities
• Serve as a central resource for prioritization decisions, helping balance workloads and address competing demands
• Analyze payer performance, contract adherence, and reimbursement trends; communicate findings to director
• Promote adherence and efficiency to standard processes and reporting
• Partner with the Director to identify revenue leakage risks and proactively implement solutions
• Contribute to special projects and ad-hoc analysis requested by leadership

Qualifications: 

Required

• B.S./B.A. degree in Finance, Accounting, Healthcare Administration, Analytics, or related field
• 6 years of experience in health are organization or health insurance company
• 4 years of experience in financial analysis, healthcare revenue cycle, or pharmacy services financial analysis
• Advanced knowledge of reimbursement methodologies, payer contracts, and claims adjudication
• Strong analytical, problem-solving, and data interpretation skills
• Demonstrated ability to manage complex issues and influence outcomes
• Advanced proficiency in Excel and data analysis tools
• Ability to design and implement policies and procedures

Preferred

• Experience specific to pharmacy services or pharmacy revenue integrity
• Pharmacy claims, reimbursement and analytical reporting preferred
• Proven ability to solve problems effectively
• Pharmacy dispensing knowledge and/or experience

Key Competencies

• Influence Without Authority – Leads through expertise, credibility, and collaboration
• Problem Solving & Escalation Management – Handles high-impact, complex issues effectively
• Operational Leadership – Guides team workflows and ensures execution excellence
• Advanced Analytical Expertise – Translates complex data into actionable insights
• Communication – Effectively conveys complex financial and operational concepts
• Continuous Improvement Mindset – Proactively identifies and implements enhancements and automation

Success Metrics

• Accuracy and timeliness of revenue integrity reporting and analysis
• Effectiveness and timeliness of escalation resolution
• Team productivity and workflow efficiency
• Stakeholder satisfaction and confidence in analytics and recommendations

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link foradditional information: https://www.fairview.org/careers/benefits/noncontract

The posted pay range is for a 40-hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.

Salary : $77,730 - $109,741