Scope of Position

The Revenue Integrity Specialist optimizes the payment cycle for retail and specialty pharmacy claims. This role ensures accurate workflow of pharmacy accounts, reviews payments for accuracy, aligns collections with contracts, and follows up with insurance companies. The specialist secures third-party payments, ensures compliance with payer contracts, and maintains accurate secondary billing processes and vendor data feeds. They advocate for efficient claim resolution, provide proactive follow-up, and identify trends to ensure process accuracy. Additionally, they contribute to scalable process improvements, respond to and defend audit requests from commercial health plans/payors, and ensure the accuracy and completeness of claims to retain reimbursement.

Position Summary

This position assists with revenue cycle related activities. These activities include but are not limited to reconciling payer remittances including unapplied cash, claim exceptions and partial pay understanding, payer denials and impact on revenue cycle, proactively communicate with onsite pharmacy staff, finance staff and insurance companies to resolve payment discrepancies. Advanced knowledge of, or experience with state, federal and PBM (Pharmacy Benefit Management/commercial health plans/payors) accreditation rules and regulations regarding pharmacy benefit and medical benefit claims billing. This position requires strong knowledge of Microsoft Excel, Microsoft Teams and other computer related skills.

Minimum Qualifications

For Hire: Bachelors in Business, healthcare or related field or equivalent combination of education and related experience or 3 years experience as a pharmacy technician. Must be registered technician with the State of Ohio Board of Pharmacy and hold active PTCB/NHA certification prior to start date.

On going: PTCB certification and Board of Pharmacy registration as a Certified pharmacy technician must be maintained for continued employment.