Pharmacy Revenue Cycle Analyst

Fairview Health Services; Shoreview (MN); On-site; USD 75,000 - 100,000; Full time

Job summary

Fairview Health Services is seeking a Revenue Cycle Analyst to analyze the pharmacy revenue cycle, optimize the payment process, and resolve payer remittance issues across retail, specialty, compounding, and long-term care settings. You will review payments for accuracy, follow up with insurance payers, and advocate for efficient claim resolution to improve margins.

The role requires collaboration with pharmacy sites and payer representatives, evaluating denials and trends, and contributing to

Qualifications

• B.S./B.A. in Business, healthcare or related field or equivalent combination of education and related experience
• 3 years healthcare reimbursement analysis, collection experience, revenue cycle process knowledge experience and/or pharmacy insurance experience
• This individual should have strong interest in learning new IS systems (Enterprise Rx, RMS StarLink, Frameworks LTC, Epic, Inmar, etc) as well as the ability to work independently
• Excellent customer service skills, proficient in English language, capable of solving problems effectively, ability to follow policies and procedures, and competent mathematical skills
• Strong critical thinking and analytical skills
• Ability to work independently and exercise independent judgment
• Ability to prioritize and deal with fluctuation in workload
• Good computer and telephone skills

Responsibilities

• Understand the overall workflow to proactively solve problems, provide analysis and evaluate trends in the revenue cycle.
• Demonstrates analytical skills including the ability to reconcile payer remittances.
• Understands the payer denials and impact on FPS revenue cycle and overall margins.
• Displays initiative to resolve 835 remittance issues including but not limited to; unapplied cash, claim exceptions and partial pays.
• Evaluates contracts, analyzes payments and proactively problem solves to optimize the pharmacy claim payment cycle.
• Provides claims resolution to ensure accuracy in the process.
• Proactively communicates with pharmacy site staff, revenue integrity operations staff, and insurance companies to escape and resolve claims payment discrepancies.
• Analyzes existing reimbursement arrangements/networks and reimbursement and operational issues with claims systems and their subsequent impact on financial results.
• Understand contracts to achieve results and department metrics; including but not limited to: Payer Days Service Outstanding, Open Accounts Receivable aging, and secondary payer billing timelines.
• Ensures applied cash targets are met for assigned payers.
• Review payment for accuracy, ensure collection according to contracts, understand and follow-up with insurance payers to leverage the revenue cycle process.
• Utilizes preferred collection procedures to obtain third party payments and ensures compliance with payer contracts.
• Ensures accuracy of secondary billing processes and related vendor data feeds into FPS systems as required.
• Understands regulatory, HMO, PPO, Federal, State and other third party payer requirements to prepare/process claims.
• Ensure optimal revenue cycle performance through evaluation, analysis and problem solving.
• Uses data for projections as part of contractual analysis.
• Completes detailed financial impact analysis of provider rate.
• Produces reports for payment variances, rejected and partial pay claims.
• Reviews aging reports that have reached certain aged categories (30, 60, 90 days, etc)
• Generates manual and on-line billing for resubmission for third party payer’s outstanding balances.
• Reviews payment process for accuracy; provides necessary follow-up.
• Communicates and resolves reimbursement issues to coordinate payer/provider relations between payers and FPS.
• Identifies and communicates trends to leadership to improve pharmacy revenue cycle performance
• Provides analysis to stakeholders with explanations of reimbursement findings and assists in identifying potential compliance issues to FPS staff
• Constantly analyzes operations and seeks process improvements to enhance revenue cycle and reduce losses
• Attend periodic meetings with payer representatives to discuss discrepancies and develop action plans
• Contribute to scalable process improvement to advance external revenue from the national strategy platform with pharmacy business office services.
• Provides revenue-cycle insights to venture partner teams and PBO vendors for product/service improvement.
• Collaborates with leadership to develop new process capabilities to improve efficiency, scalability and margin for FPS.
• Uses problem solving and critical thinking to define and resolve work problems

Skills

Reimbursement analysis

Independent work

Customer service

Analytical skills

English proficiency

Problem solving

Time management

Microsoft Excel

Communication skills

Education

Bachelor's degree

Tools

Epic

Enterprise Rx

RMS StarLink

Frameworks LTC

Inmar

Job description

Fairview Health Services is seeking a Revenue Cycle Analyst to analyze the pharmacy revenue cycle, optimize the payment process, and resolve payer remittance issues across retail, specialty, compounding, and long-term care settings. You will review payments for accuracy, follow up with insurance payers, and advocate for efficient claim resolution to improve margins.

The role requires collaboration with pharmacy sites and payer representatives, evaluating denials and trends, and contributing to