Lead Charge Master, Revenue Integrity Analyst (Pharmacy) (5963)

A Brief Overview
Responsible for ensuring accurate and appropriate pharmacy charging, billing compliance, reporting of revenue and maintain integrity of systems in compliance with regulatory guidelines. Serves as a liaison between pharmacy, finance, and ancillary departments regarding revenue management initiatives and issues. Supports pharmacy network contracting process and maintain compliance with credentialing requirements. The lead technician will also provide operational oversight and support to the pharmacy revenue integrity team members.

What you will do

• Revenue Integrity and Charge Master Management: • Maintains and update pharmacy-related items within the hospital charge master, ensuring correct HCPCS, NDC, CPT, multipliers, units of measure, and pricing. • Monitors medication charges for accuracy and resolve discrepancies. • Collaborates with Pharmacy, Finance, HIM, Coding, and Compliance on charge integrity issues. • Reviews medication builds within the EMR to ensure alignment with charge master parameters. • Conducts assigned audits by researching documentation, analyze information, and provides recommendations to improve flow of claim and enters corrections into systems. • Serves as a liaison to include regular reviews of CPT codes, revenue codes, review of monthly standard CDM error report.
• Billing Compliance and Documentation: • Ensures pharmacy billing practices adhere to federal, state, and payer regulations and guidelines. • Interacts with ancillary departments to obtain additional information needed to properly bill account based on medical record. • Evaluates current charging and coding structures and processes in clinical/ancillary departments to ensure appropriate capture and reporting of revenue with government and third-party payor requirements. • Serves as a liaison to include regular reviews of CPT codes, revenue codes, review of monthly standard CDM error report. • Reviews denial trends for documentation or charging issue opportunities. • Monitors compliance with 340B and inpatient/outpatient billing structures. • Verifies correct use of revenue codes, billable units, and modifiers. • Supports pharmacy audit preparation and respond to audit requests. • Coordinates educational in-services to Inpatient Pharmacy and Outpatient Pharmacy staff related to charging and billing issues. • Conducts routine audits of financial assistance programs, including charity care, manufacturer assistance, copay assistance, foundation grants, and other patient support programs.
• Data Analysis and Reporting: • Generates and analyzes revenue reports to identify trends and issues. • Tracks and reports revenue capture metrics. • Identifies patterns in missed charges and recommend improvements. • Coordinates the gathering of specific information from Pharmacy, Accounting, Patient Financial Services, and other departments involved in the development of financial reports/analysis. • Maintains reports, records and files for administration and compliance purposes.
• Workflow Leadership and Team Support: • Provides guidance to pharmacy technicians. • Trains staff on charging workflows and documentation. • Participate in evaluations and mentoring.
• Contracting Support: Credentialing and Compliance: • Prepares, distributes, and electronically tracks retail and specialty pharmacy contracts and agreements. • Reviews contract submissions for completeness, accuracy, and compliance with organizational guidelines. • Maintains up-to-date digital records of state board licenses, contract statuses and follow up with pharmacies via e-mail or electronic communications tools. • Ensures executed contracts are uploaded, indexed and securely stores in electronic systems. • Collaborates with Managed Care Department to review and monitor pharmacy reimbursement under managed care contracts to ensure payments align with contractual terms and fee schedules.

Process Improvement and System Optimization: • Recommends improvements for charge capture and medication utilization workflows. • Participates in EMR upgrades and system development and testing. • Collaborates with Pharmacy Informatics team to test charge flows and medication build. • Utilizes understanding of clinical and financial system processing to implement department requested changes. • Performs leadership role in intermediate level process improvement projects. • Trains operations staff and/or new team members on new processes, guidelines or regulations. • Serve as a point of contact for pharmacies, answering questions and assist with contracting and credentialing needs. • Generates electronic reports related to contract progress, credentialing state, expirations, and compliance metrics.

Qualifications

• Bachelor's Degree Bachelor's Degree and/or successful completion of Pharmacy Technician program Preferred
• Certified Pharmacy Technician Upon Hire Required and
• State Board of Tennessee Board of Pharmacy Certified Pharmacy Technician License Upon Hire Required
• Minimum 2 years experience as a Pharmacy Technician Required in retail, specialty, hospital or administration settings and strong accuracy and attention to detail in digital data handling. Required
• • Experience in charge master maintenance, hospital billing, or revenue integrity. • Knowledge in pharmacy contracting, credentialing, provider enrollment, or payer operations. • Experience in leadership. • Familiarity with PBM contracting standards and credentialing requirements. • Knowledge of pharmacy regulatory guidelines (state boards, DEA, NPI, CMS). Preferred

Physical Demands

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Constantly
• Lifting - Rarely
• Carrying - Rarely
• Pushing - Rarely
• Pulling - Rarely
• Climbing - Rarely
• Balancing - Rarely
• Stooping - Rarely
• Kneeling - Rarely
• Crouching - Rarely
• Crawling - Rarely
• Reaching - Rarely
• Handling - Occasionally
• Grasping - Occasionally
• Feeling - Rarely
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Frequently
• Eye/Hand/Foot Coordination - Frequently