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About the Role

The Manager-Billing and Medical Operations is responsible for the supervision and management of all pharmacy and medical claims processing at Reliance Rx. This role will also manage the billing and medical operations teams, monitor daily workflow and phone metrics, and complete daily audits of billing queues to ensure accurate and timely processing. The position is accountable for reimbursement accuracy, accounts receivable oversight, and the continuous improvement of billing processes and systems.

Responsibilities

Oversee all NCPDP claims processing, medical claims submission via 837 and CMS1500, copay assistance billing, and paper claims submission when necessary.
Serve as the subject matter expert for all billing issues and development of best billing practices.
Review escalated billing issues and perform root cause analysis on all billing discrepancies.
Responsible for associate follow up, re-training, and disciplinary action when needed.
Maintain a high level of knowledge of regulatory requirements for billing (i.e. Medicare and Medicaid).
Ensure payor compliance by monitoring claims and ensuring all service level agreements and shipping timelines are met.
Provide on-the-fly coaching as necessary.
Manage and develop the Billing Specialist team and monitor productivity and performance metrics.
Oversee patient and insurance accounts receivable for Reliance Rx.
Monitor workflow from claim submission and payment posting through denial resolution.
Monitor reimbursement trends, insurance, and patient account receivable, denial management, and aging balances.
Identify root causes of billing discrepancies and reimbursement errors and implement corrective action plans.
Oversee quality assurance audits to ensure compliance with payer contractual requirements and internal standards.
Evaluate billing system enhancements and implement process improvements to support operational efficiency and compliance.
Facilitate training as needed.
Lead the submission, maintenance, and management of 837 files and work directly with payors when necessary for implementation and testing.
Manage all Medical Benefit Orders being administered by providers/clinics.
Ensure all orders are received ahead of scheduled appointment dates.
Work with offices directly on best practices when necessary.
Partner internally with Finance, Infusion, and Account Management to resolve billing discrepancies and improve revenue cycle performance and management.
Work in parallel with infusion, clinical account pharmacists, and regional sales executives for strategic business development efforts to increase service offerings and maintain service excellence.
Collaborate to achieve departmental goals, quality metrics, and organizational objectives.

Requirements

Bachelor’s degree required. An additional four (4) years of experience will be considered in lieu of degree.
Five (5) years of experience with third party claims billing, patient collections, or high-volume pharmacy required, to include two (2) years of specialty pharmacy, specialty infusion or related business.
Two (2) years of progressive leadership/management responsibility required.
Strong leadership, coaching and mentoring skills with the ability to identify, address and resolve associate issues objectively and in a timely manner.
Excellent written and verbal communication skills and problem-solving skills required, including the capability to absorb new concepts and act as a role model/mentor to billing specialists.
Excellent organizational, process and time management skills required with the ability to handle multiple tasks.
Proven examples of displaying the Reliance values: Collaborative, Accessible, Results-Oriented, Empowering, and Supportive.

Skills

Pharmacy and medical claims processing
Billing and medical operations team management
Daily workflow metrics monitoring
Daily phone metrics monitoring
Daily audits of billing queues
Claims processing system upgrades and enhancements assessment
Best business practices implementation
Pharmacy NCPDP claims
Medical claims processing
837 set up
Payor collaboration for 837 file development
837 claim submission
Claim timeliness
Denial corrections and resubmission
Payment accuracy
Revenue cycle performance optimization
Complex billing issue resolution
Compliance with contractual and regulatory requirements
Operational excellence
Reimbursement accuracy
Accounts receivable oversight
Continuous improvement of billing processes and systems
Specialty pharmacy and copay assistance/foundation billing
Medical billing and 837 claim transaction experience
NCPDP and medical claim responses knowledge
Regulatory requirements for billing (i.e. Medicare and Medicaid)
Patient and insurance accounts receivable management
Reimbursement trends monitoring
Denial management
Aging balances management
Quality assurance audits
Billing system enhancements evaluation
Process improvements implementation
Training facilitation
837 file management
Medical Benefit Orders administration
Internal collaboration (Finance, Infusion, Account Management)
Strategic business development efforts
Service excellence maintenance

Location

Williamsville

Work Type

Hybrid

Experience Level

Manager
2 years of progressive leadership/management responsibility

Education Level

Bachelor's degree

Salary/Compensations

$76,500 - $95,000 annually

Benefits

Scorecard incentive
Full range of benefits
Generous paid time off

About the Company

We're excited about the potential people bring to our organization.
You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

Equal Opportunity

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.
Click here for additional EEO/AAP or Reasonable Accommodation information.