Billing Specialist III

guardianpharmacy; Cedar Rapids (IA); On-site; USD 42,000 - 64,000; Full time

Job summary

Right Dose Pharmacy, a member of the Guardian family, seeks a Billing Specialist III in Cedar Rapids, Iowa. You will manage patient eligibility, benefits, and billing inquiries while ensuring accuracy and regulatory compliance to support seniors and complex care needs.

Responsibilities include billing processing, claims adjudication, and ensuring timely payments and documentation. A pharmacy tech background and Medicare expertise are highly valued in a fast-paced team environment.

Qualifications

• High School Diploma or GED required.
• Pharmacy Technician license/certification/registration per state requirements; National Certification preferred (PTCB).
• 3+ years related experience.

Responsibilities

• Research and establish patient eligibility coverage with insurance providers including private individuals and/or government entities.
• Maintain and audit patient files and documentation to defend third party audits and ensure payer and company compliance.
• Provide assistance and timely response to all billing inquiries via phone or electronic communications.
• Run Medicare plan comparisons during open enrollment and special enrollment periods.
• Process patient payments, returns, and credits; transmit credit card payments as needed.
• Perform prescription claims adjudication including communication with insurance companies regarding rejected claims and re-bill as necessary.
• Demonstrate advanced knowledge of pharmacy facility billing requirements and PHI/ HIPAA compliance.

Skills

Work ethic/Integrity

Relational

Strategy and Planning

Problem Solving

Team Oriented

Education

High School Diploma or GED

Pharmacy Technician license/certification/registration per state requirements

National Certification (PTCB) preferred

Job description

Cedar Rapids, Iowa, United States of America Extraordinary Care. Extraordinary Careers.

With one of the nation's largest, most innovative long-term care pharmacy services providers, there is no limit to the growth of your career.

Right Dose Pharmacy , a member of the Guardian family of pharmacies, has an exciting opportunity for you to join our rapidly growing team in Cedar Rapids, Iowa .

Why Right Dose Pharmacy ?

We're reimagining medication management and transforming care.

Who We Are and What We're About:

Our core focus is delivering customized medication management solutions to support healthcare organizations serving seniors and individuals with complex care needs. With our comprehensive suite of tech-enabled pharmacy services and a dedicated team of professionals committed to enriching the lives of those we serve, we are redefining how pharmacy care is delivered.

We offer an opportunity to learn and grow your career in a fast-paced, diverse, and inclusive environment. If you are looking for a challenging, team-oriented environment in which you can put your expertise to work, then this is the place for you.

Responsible for processing customer bills and insurance claims in an accurate and timely manner. This includes assisting with all daily and month-end billing functions, procedures and reporting. Provides excellent customer service to patients, caregivers, medical providers and insurance carriers. The Billing Specialist III serves as a subject matter expert and departmental resource.

ATTRIBUTES REQUIRED:

• Work Ethic/Integrity - must possess intrinsic drive to excel coupled with values in line with company philosophy.
• Relational - ability to build relationships with business unit management and become "trusted advisor."
• Strategy and Planning - ability to think ahead, plan and manage time efficiently.
• Problem Solving - ability to analyze causes and solve problems at functional level.
• Team Oriented - ability to work effectively and collaboratively with all team members.

ESSENTIAL JOB FUNCTIONS (include the following):

• Research and establish patient eligibility coverage with insurance providers including private individuals and/or government entities. Reverify benefit coverage criteria as needed for claims follow up. Accurately enters and/or updates patient/insurance information into billing system.
• Maintain and continually audit patient files and corresponding documentation necessary to defend third party audits and ensure payer and company compliance. Accurately enter patient information into the pharmacy system.
• Provide assistance and timely response to all billing customer inquiries via phone or electronic communications. Using advanced knowledge, independently, troubleshoot, research and resolve patient billing issues regarding insurance eligibility, coverage, and related benefits. Uses advanced knowledge to independently resolve customer service issues that require judgement and critical thinking.
• Provide guidance and support to resident or responsible party by running Medicare plan comparisons during open enrollment and special enrollment periods. Proactively review patient profiles, drug regimens and insurance coverage to evaluate options to save resident money.
• Responsible for completion of daily census, admit, discharge, and room changes for the facilities assigned.
• Process patient payments, returns, and credits. Transmit individual credit card payments as needed.
• Ma y pursue payment from delinquent accounts and make payment arrangements.
• Research, identify and organize requested audit documentation in timely manner.
• Perform prescription claims adjudication including communication with insurance companies regarding rejected claims, eligibility, prior authorizations or other issues as needed. Make corrections as needed and rebill claims as necessary.
• Through prior experience and cross training, demonstrate advanced knowledge and understanding in pharmacy facility billing requirements (Medicare, Medicaid, Prescription Drug Plans (PDPs) and Third-Party Insurances) and working/functional knowledge of other pharmacy departmental functions
• Serve as subject matter expert and departmental resource in Pharmacy information systems and workflow. This includes using pharmacy systems to process prior authorizations, resolve rejections, produce various reports as necessary, and complete billing functions in a timely manner and with a high degree of accuracy.
• Consistently exceed pharmacy's established accuracy and productivity levels.
• Follow all applicable government regulations including HIPAA.
• Work as a collaborative team member to meet the service goals of the pharmacy.
• Other essential functions and duties may be assigned as needed.

EDUCATION AND/OR CERTIFICATIONS:

• High School Diploma or GED required.
• Pharmacy Technician license/certification/registration per state requirements; National Certification preferred (PTCB) may be required (pharmacy specific).

SKILLS AND QUALIFICATIONS:

3+ years related