Pharmacy Billing Specialist

Indian Health Service; Klamath Falls (OR); On-site; USD 55,000 - 75,000; Full time

Job summary

Klamath Tribal Health & Family Services seeks an experienced Pharmacy Billing Specialist to support accurate claims processing, prior authorizations, and timely reconciliation of payments. You will work under Pharmacy Billing Manager supervision to uphold billing accuracy and compliant procedures within the tribal health system.

The role requires extensive national certification for pharmacy technicians, Oregon licensure, and a strong background in fraud prevention and healthcare compliance.

Qualifications

• High School Diploma or Equivalent required.
• Must hold Oregon Pharmacy Technician Licensure.
• Pharmacy Technician Certification (CPhT) required.
• At least ten years as Nationally Certified Pharmacy Technician.
• Background check and adherence to health policies required.

Responsibilities

• Review and audit pharmacy claims and billing for accuracy.
• Support pharmacy staff with billing questions and needs.
• Maintain accurate demographic and billing information.
• Submit prior authorizations and reconcile payments timely.
• Assist with pharmacy audits and fraud, waste and abuse training.

Skills

Computer skills

Records management

Fraud, waste and abuse awareness

Education

High School Diploma or Equivalent

Certified Oregon Pharmacy Technician Licensure

Pharmacy Technician Certification (CPhT)

Job description

Summary

Klamath Tribal Health & Family Services is a division of the Klamath Tribes and is responsible for providing healthcare services to members and descendants of the Klamath Tribes and to other persons of Indian descent of a Federally Recognized Tribe.The Mission of the Klamath Tribes is to protect, preserve, and enhance the spiritual, cultural, and physical values and resources of the Klamath, Modoc, and Yahooskin Peoples, by maintaining the customs and heritage of our ancestors. To establish a comprehensive unity by fostering the enhancement of spiritual and cultural values through a government whose function is to protect the human and cultural resources, treaty rights, and to provide for the development and delivery of social and economic opportunities for our People through effective leadership. To learn more, visit The Klamath Tribes.

Working under the direct supervision of the Pharmacy Billing Manager, the incumbent shall perform a variety of technical billing functions to support the mission of KTHFS. The incumbent will provide support to Pharmacy staff in respect to billing of prescriptions claims and services.

More info about area

http://www.klamathtribalhealth.org

Job Announcement Flyer

Pharmacy Billing Specialist.pdf [pdf - 372.36 KB]

Duties

• Proactively gain knowledge to maintain a high level of industry knowledge related to the review/ audit and billing of pharmacy claims for prescriptions and pharmacy services.
• Collaborate with and be available to pharmacy personnel for timely response and support for billing questions and needs.
• Build and retain positive and professional relationships with external KTHFS business partners.
• Use implemented and established processes to assure and maintain accurate demographic and billing information.
• Use implemented high-quality pre and post claims review of each prescription filled and pharmacy services to be billed. Ensure claims submission adheres to KTHFS values, mission and vision, ensuring claims are precisely and legally adjudicated and billed in effort to obtain maximum allowable reimbursement.
• Proactively identify opportunities to improve alternative resources for patients. Effectively work with KTHFS Patient Benefits personnel to screen and refer for potential eligibility of alternate resources.
• Responsible for the request and submission of pharmacy prescription prior authorization requests.
• Accurately and efficiently post pharmacy payments in a timely manner per protocol when requested.
• Use implemented process to ensure successful reconciliation of pharmacy claims working to reduce denials, receive payment and receipt of all claims.
• Proactively review claims history and rebill underpayments and non-payments, claims missed on insurance and/or errors found with the review/audit process.
• Assist the Pharmacy Staff with pharmacy audits.
• Communicate with tribal members, descendants, caregivers, and other health care professionals, regarding Prior Authorizations according to the Pharmacy Business Office SOP.
• Maintain training specific to Prior Authorizations and the detection, correction and prevention of fraud, waste and abuse in the delivery of Medicare and Medicaid benefits.
• Maintain other standards of annual training required for health care workers or any training required by KTHFS such as Blood Borne Pathogen, HIPAA Privacy and Security, and others as deemed necessary.
• Attend and participate in regular Pharmacy Billing Office and other meetings when requested by Manager.(The attached pdf job announcement includes the complete list)

Qualifications

QUALIFICATIONS, EXPERIENCE, EDUCATIONMinimum Qualifications: Failure to comply with minimum position requirements may result in termination of employment.

• REQUIRED to possess a High School Diploma or Equivalent. (Must submit copy of diploma or transcripts with application.)
• REQUIRED to possess a Certified Oregon Pharmacy Technician Licensure. (Must submit a copy of certification with application.)
• REQUIRED to possess a Pharmacy Technician Certification (CPhT). (Must submit a copy of certification with application.)
• REQUIRED to have at least ten (10) years working as an experienced Nationally Certified Pharmacy Technician.
• REQUIRED to be free from exclusion from providing Federal health care benefits including Medicare and Medicaid as per the Federal OIG and GSA exclusion lists.
• REQUIRED to receive training specifically in the detection, correction and prevention of fraud, waste and abuse in the delivery of Medicare and Medicaid benefits. Training shall be performed within 30 days of hire and at least annually thereafter
• REQUIRED to have excellent computer skills and word processor experience.
• REQUIRED to have knowledge of records management.
• REQUIRED to submit to annual TB skin testing and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers.
• REQUIRED to submit to a background and character investigation, as per Tribal policy. Following hire must immediately report to Human Resource any citation, arrest, conviction for a misdemeanor or felony crime.

Preferred Qualifications

• Possess a Prior Authorization Certified Specialist Certification
• Graduation from an accredited Pharmacy Technician training school.
• Applicable specialized experience billing, auditing or managing pharmacy benefits.

Announcement #

KTHFS-4513999

Who May Apply?

All Groups of Qualified Individuals