Provide analysis and demonstrate understanding of revenue cycle management to optimize the payment cycle. Ensure maintenance and understanding of the overall workflow of pharmacy accounts. Review payment for accuracy, ensure collection according to contracts, understand and follow-up with insurance companies to leverage the revenue process. Utilize preferred collection procedures to obtain insurance payments and ensure compliance with Fairview payer contracts. Ensure accuracy of Fairview Pharmacy Services (FPS) secondary billing processes and related vendor data feeds into FPS systems as required. Advocate on behalf of FPS to ensure the most efficient processes regarding claim resolution. Evaluate denials. Provide proactive and ongoing follow-up and problem solving with insurance companies and pharmacy sites to identify trends, communicate proactively, and ensure accuracy in the process.
Understand the overall workflow to proactively solve problems, provide analysis and evaluate trends in the revenue cycle.
Demonstrated analytical skills including ability to reconcile payer remittances
Understanding of payer denials and impact on FPS revenue cycle
Display initiative to resolve 835 remittance issues including but not limited to; unapplied cash, claim exceptions and partial pays.
Evaluate contracts, analyze payments and proactively problem solve to optimize the payment cycle.
Provide claims resolution to ensure accuracy in the process.
Proactively communicate with pharmacy site staff and insurance companies regarding resolution
Analyze 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 DSO equal or exceeds department goals
A/R % over 60 days meet or exceeds department goals
Ensured timely submission of secondary payer billing which meets or exceeds department goals.
Ensure applied cash targets are met for assigned payers.
Review payment for accuracy, ensure collection according to contracts, understand and follow-up with insurance companies to leverage the revenue process.
Utilize preferred collection procedures to obtain insurance payments and ensure compliance with Fairview payer contracts.
Ensure accuracy of FPS secondary billing processes and related vendor data feeds into FPS systems as required.
Understand regulatory, HMO, PPO, Federal, State and other third party payer requirements needed to prepare and or process claims.
Ensure optimal revenue cycle performance through evaluation, analysis and problem solving.
Use data for projections as part of contractual analysis.
Complete detailed financial impact analysis of provider rate.
Produce reports for payment variances, rejected, denied and reduced claims
Review aging reports that have reached certain aged categories (30, 60, 90 days, etc)
Generate manual and on-line billing for resubmission for third party payers outstanding balances.
Review payment process for accuracy; provide necessary follow-up
Communicate and resolve reimbursement issues to coordinate payer/provider relations between payers and Pharmacy Services
Identify and communicate trends to improve overall revenue cycle performance
Provide analysis to stakeholders with explanations of reimbursement finding from assigned providers utilizing Excel and displaying initiative to assist in identifying potential compliance issues to FPS staff and make recommendations to Finance management for resolution.
Constantly analyze operations, and attempt to improve processes in order to provide better customer service and improve the revenue cycle (including minimizing controllable loss categories, i.e. Timely Filing).
Bachelors in Business, healthcare or related field or equivalent combination of education and
Bachelors Degree in Business or related field.
Three years healthcare reimbursement analysis, collection experience, revenue cycle process knowledge experience and/or pharmacy insurance experience.
Five years pharmacy reimbursement analysis and collection experience including experience with Medicare, Medicaid and Commercial Payer experience. Pharmacy dispensing knowledge and/or experience preferred.
Excellent communication skills. Proficient in the English language. Proficient math skills. Proficiency with PC software and A/R systems essential including basic typing skills. Ability to communicate both written and verbal information in a clear, concise, accurate and considerate manner. Ability to deal professionally, courteously and efficiently and to remain calm under stress. Proven ability to problem solve effectively.
Special Considerations(list unique elements of this position, if any)
Respect the confidentiality of all information, including information regarding patients, staff members or Fairview business issues, and share information only with those who need to know.
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, ...Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.