Overview:
The Infusion and Specialty Drug Revenue Cycle Specialist is responsible for managing the accounts receivable (AR) processes related to physician-administered drugs, including infusion therapies, injectable medications, and buy-and-bill pharmaceuticals. This includes verifying insurance coverage, submitting claims for drugs billed under the medical benefit, resolving billing discrepancies, and ensuring timely reimbursement from payers. This role requires collaboration with pharmacy teams, clinical staff, healthcare providers, and insurance companies to streamline the revenue cycle and minimize denials.
Responsibilities:
Essential Functions
Claims Management:
- Submit accurate claims for infusion therapies, injectable medications, and physician-administered drugs to insurance payers.
- Track claims to ensure timely processing and reimbursement.
- Identify and address claim rejections and denials promptly.
Accounts Receivable Monitoring:
- Reconcile payments and outstanding balances for infusion and injectable drug claims.
- Maintain detailed records of payer communications and payment status.
- Follow up on unpaid or underpaid claims.
Insurance Verification:
- Confirm insurance eligibility and coverage for infusion therapies and physician-administered drugs.
- Collaborate with pharmacy and clinical teams to obtain prior authorizations when required.
- Compliance and Documentation:
- Ensure claims comply with payer policies, coding standards, and regulations.
- Maintain organized and accurate documentation for audit purposes.
Process Improvement:
- Identify opportunities to optimize the infusion and medical benefit drug billing process.
- Implement solutions to enhance efficiency and reduce denials.
Knowledge, Skills and Abilities:
- Advanced knowledge of medical terminology, ICD 10, CPT, HCPCS coding and HIPAA requirements.
- Ability to communicate effectively, both orally and in writing
- Demonstrated proficiency in the use of computers and commonly used software, including electronic medical records (EMR).
- Extensive knowledge and experience with commercial, government and state billing and reimbursement procedures.
- Proficiency in insurance verification, prior authorization, and AR follow-up.
- Attention to detail, organizational skills, customer service orientation, and analytical thinking.
- Through leadership and by example, ensures that services are provided in accordance with state and federal regulations, organizational policy, and accreditation/compliance requirements.
- Promptly identifies issues and report them to their direct supervisor.
- Maintain regular and predictable attendance.
- Acts in accordance with Community Care’s mission and values, while serving as a role model for ethical behavior.
Qualifications:
Minimum Education:
- High School Diploma or equivalent (higher degree accepted)
Minimum Experience:
- 2 years of experience in infusion billing, buy-and-bill processes, specialty pharmacy billing, Part B drug billing, or medical benefit drug reimbursement. Experience in oncology, rheumatology, or infusion center settings is highly desirable.