Manager, Billing & Operations

Independent Health; United States; Hybrid; USD 77,000 - 95,000; Full time

Job summary

Independent Health in Williamsville, NY is seeking a Manager-Billing and Medical Operations to supervise pharmacy and medical claims processing, manage the billing teams, and ensure accurate, timely submissions for 837 and CMS1500 workflows.

You will partner with payors and internal departments to optimize revenue cycle performance, drive process improvements, and maintain regulatory compliance. Hybrid onsite role; immigration sponsorship not offered.

Qualifications

• Bachelor’s degree required with 4 years of alternate experience considered.
• 5+ years of third party claims billing, patient collections, or high-volume pharmacy.
• 2+ years of progressive leadership/management experience.
• Specialty pharmacy experience and 837 claim transaction familiarity preferred.
• Strong leadership, communication and problem-solving skills; regulatory compliance knowledge.

Responsibilities

• Oversee all NCPDP claims processing and medical claims submission (837 and CMS1500).
• Train team on differences between pharmacy benefits and medical claims.
• Develop best billing practices and resolve escalated issues with root-cause analysis.
• Monitor SLA adherence, payor compliance, and reimbursement trends.
• Lead Billing Specialist team and manage accounts receivable for Reliance Rx.

Skills

Leadership

Billing & Revenue Cycle

Communication

Problem solving

Education

Bachelor’s degree

Four years experience in lieu of degree

Tools

NCPDP systems

837/CMS1500 processing

Job description

FIND YOUR FUTURE We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

Overview The Manager-Billing and Medical Operations is responsible for the supervision and management of all pharmacy and medical claims processing at Reliance Rx. In this role, the Manager-Billing and Medical Operations will also be responsible for the management of the billing and medical operations teams. This will include monitoring daily workflow metrics and phone metrics, as well as completing daily audits of the billing queues to ensure accurate and timely processing based on payor and internal shipping time requirements. They will assess any claims processing system upgrades and enhancements and ensure best business practices are being followed throughout the company. The Manger- Billing and Medical Operations will not only oversee pharmacy NCPDP claims, but they will also have a high level of experience and knowledge with medical claims processing and 837 set up. They will be expected to work with payors on 837 file development, 837 claim submission, timeliness of submitted claims, denials corrections and resubmission, and payment accuracy. The Billing Manager collaborates with internal departments, payors, and external stakeholders to optimize revenue cycle performance, resolve complex billing issues, maintain compliance with contractual and regulatory requirements, and drive operational excellence. This position is accountable for reimbursement accuracy, accounts receivable oversight, and the continuous improvement of billing processes and systems at Reliance Rx.

Qualifications

• Bachelor’s degree required.
• An additional four (4) years of experience will be considered in lieu of degree.
• Five (5) years of experience with third party claims billing, patient collections, or high-volume pharmacy required, to include two (2) years of specialty pharmacy, specialty infusion or related business.
• Two (2) years of progressive leadership/management responsibility required.
• Specialty pharmacy and copay assistance/foundation billing strongly preferred.
• Medical billing and 837 claim transaction experience strongly preferred.
• Strong leadership, coaching and mentoring skills with the ability to identify, address and resolve associate issues objectively and in a timely manner.
• Excellent written and verbal communication skills and problem-solving skills required, including the capability to absorb new concepts and act as a role model/mentor to billing specialists.
• Excellent organizational, process and time management skills required with the ability to handle multiple tasks.
• Proven examples of displaying the Reliance values: Collaborative, Accessible, Results-Oriented, Empowering, and Supportive.

Essential Accountabilities

• Oversee all NCPDP claims processing, medical claims submission via 837 and CMS1500, copay assistance billing, and paper claims submission when necessary.
• Subject matter expert on pharmacy benefits vs medical benefits and NCPDP claims vs medical claims.
• Train team on the differences of each type of benefit/claim.
• Serve as the subject matter expert for all billing issues and development of best billing practices.
• This will include reviewing escalated billing issues and performing root cause analysis on all billing discrepancies.
• Responsible for associate follow up, re-training, and disciplinary action when needed.
• Knowledgeable on NCPDP and medical claim responses, including how to resolve rejections and read paid claim responses to identify over/under payments or other reimbursement discrepancies.
• Maintain a high level of knowledge of regulatory requirements for billing (i.e. Medicare and Medicaid).
• Ensure payor compliance by monitoring claims and ensuring all service level agreements and shipping timelines are met.
• Directly accountable for observing and reviewing billing practices at Reliance Rx; providing on-the-fly coaching as necessary.
• This will include managing and developing the Billing Specialist team and monitoring productivity and performance metrics.
• Oversee patient and insurance accounts receivable for Reliance Rx.
• Monitoring workflow from claim submission and payment posting through denial resolution.
• Monitor reimbursement trends, insurance, and patient account receivable, denial management, and aging balances.
• Identify root causes of billing discrepancies and reimbursement errors and implement corrective action plans.
• Oversee quality assurance audits to ensure compliance with payer contractual requirements and internal standards.
• Evaluate billing system enhancements and implement process improvements to support operational efficiency and compliance and facilitate training as needed.
• Lead the submission, maintenance, and management of 837 files and work directly with payors when necessary for implementation and testing.
• Management of all Medical Benefit Orders being administered by providers/clinics, ensure all orders are received ahead of scheduled appointment dates.
• This will also include working with offices directly on best practices when necessary.
• Partner internally with Finance, Infusion, and Account Management to resolve billing discrepancies and improve revenue cycle performance and management.
• Work in parallel with infusion, clinical account pharmacists, and regional sales executives for strategic business development efforts to increase service offerings and maintain service excellence.
• Collaborate to achieve departmental goals, quality metrics, and organizational objectives.

Hybrid position with onsite attendance required at our Williamsville location.

Immigration or work visa sponsorship will not be provided for this position.

Hiring Compensation Range: $76,500 - $95,000 annually Compensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Aff…?

The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being. Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation.

Our culture sets us apart. Our core values drive who we are and the work we do. As a member of our family, you’re part of something special, in your work and in the community.

We understand and appreciate that everyone has unique experiences, perspectives and identities which is why we pledge to create a safe space where all people and ideas are welcomed. We are here to continue learning and to generate important dialog. We are committed to doing what matters most - reaching out, working together, and caring for our community. A healthy community benefits everyone who lives in it. You too can be part of making difference in the lives of others, together we achieve so much more.

Please note, we do not accept unsolicited resumes. We do not accept resumes from headhunters, placement agencies, or other suppliers that have not signed a formal agreement with us.