Pharmacy Biller

Description:

The Pharmacy Biller is responsible for the accurate and timely processing of pharmacy billing and reimbursement activities. This role reviews claims, resolves denials, and supports patients with billing and insurance inquiries. The position collaborates closely with internal teams and third-party payors to ensure compliance with applicable regulations and supports the financial performance of the pharmacy.

PRINCIPAL ACTIVITIES & RESPONSIBILITIES

Prepares, submits, and monitors pharmacy billing claims to ensure accurate and timely reimbursement from third party payors. Researches, resolves, and follows up on denied or rejected claims, including initiating appeals when appropriate. Initiates and tracks prior authorizations to support successful medication claim processing. Contacts third-party payors via phone, email, or fax to follow up on outstanding accounts (30, 60, 90, or 120+ days). Posts payments, adjustments, and reconciles accounts to maintain accurate billing records. Assists patients with billing inquiries, insurance coverage questions, and payment responsibilities. Maintains current knowledge of Medicare, Medicaid, Workers' Compensation, VA, and private insurance requirements, including coverage guidelines and billing regulations. Ensures compliances with HIPAA and all applicable federal, state, and organizational billing regulations and policies. Monitors formulary and coverage changes for key payors and communicates billing regulations and policies. Monitors formulary and coverage changes for key payors and communicates updates to the pharmacy team to reduce claim rejections and delays. Collaborates with Pharmacy, Business Office, Patient Financial Services, Alternate Resources and IT teams to support efficient billing processes and resolve claim issues. Tracks and analyzes billing trends, reimbursement patterns, and denial rates; provides reports and recommendations for process improvement to department leadership. Monitors and supports billing procedures and systems to improve efficiency, accuracy, and compliance. Maintains accurate and complete billing documentation and records for auditing and reporting purposes. Supports the implementation and reporting of pharmacy related billing programs and initiatives. Collaborates efficiently and effectively while consistently demonstrating professionalism and maintaining positive, respectful relationships with internal teams, external partners, and Tribal members. Other duties as directed by management.

LEVEL OF AUTHORITY & RESTRICTIONS

This position requires working independently without overseeing others, with minimal authority in decision-making.

PHYSICAL & MENTAL DEMANDS

Must be able to walk, talk, hear, use hands to handle, feel or operate objects, tools, or controls, and reach with hands and arms. Vision abilities required by this job include close vision and the ability to adjust focus. May be required to push, pull, lift, and/or carry up to 30 pounds. Must be able to stand, walk, reach with hands and arms, and climb or balance. Must be able to sit and type/work on a computer. Must be able to stand for long periods of time.

WORKING CONDITIONS & ENVIRONMENT

Moderate noise level with frequent interruptions and distractions. Must be willing and able to travel both locally and within the CTCLUSI service delivery area and work at locations other than Three Rivers Health Center.

LOCATION

Three Rivers Health Center 150 S. Wall Street Coos Bay, OR 97439

Requirements:

Must be 18 years of age or older. Minimum of two (2) years of experience in medical billing, pharmacy billing, or a related healthcare revenue cycle role. Working knowledge of pharmacy or medical billing terminology and coding standards (e.g.

NCPDP, HCPCS, ICD-10

). Experience and proficiency in the use of Microsoft products (Excel, Outlook, PowerPoint, Word, etc.). Proficient in using electron health records (HER) and pharmacy information systems for documentation and medication management. Strong organizational skills with the ability to prioritize tasks, manage time effectively, and work in a fast-paced environment. Ability to communicate clearly and effectively in English, verbally, in writing or by other acceptable means. This position is considered a covered role. A state criminal background check and fingerprint-based background check will be required as a condition of employment. This position is designated as safety-sensitive and is subject to pre-employment and other authorized drug and alcohol testing in accordance with company policy. Please note that the use of marijuana is prohibited for employees in this position, regardless of state legalization status. Must have employment eligibility in the U.S. Indian preference will be observed in the hiring process.