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About the Role
The Senior Specialist, Pharmacy Revenue Recovery serves as an experienced pharmacy revenue cycle professional responsible for identifying, investigating, and resolving complex billing, reimbursement, payment, audit, and revenue recovery issues. The role independently works financial discrepancies through resolution, reconciles claim activity to actual payments, identifies opportunities to recover missed reimbursement, and helps address recurring issues that contribute to revenue leakage or financial risk.
Responsibilities
- Investigate unpaid, underpaid, rejected, denied, reversed, recouped, or otherwise unresolved pharmacy claims and pursue appropriate resolution.
- Review claim, payer, eligibility, coordination of benefits, reimbursement, and payment information to identify discrepancies and determine appropriate corrective action.
- Correct or coordinate correction and resubmission of claims and follow issues through documented resolution and, where applicable, confirmed payment.
- Review reimbursement discrepancies, payer takebacks, recoupments, negative-margin prescriptions, and other potential revenue recovery opportunities.
- Reconcile original billing, reversals, adjustments, rebilling, recoupments, payment activity, and posting changes to determine the complete financial outcome of complex claims.
- Coordinate responses to payer and pharmacy benefit manager audits and appeals, including gathering supporting documentation, tracking deadlines, and following outstanding matters through resolution.
- Maintain accurate tracking of recovery opportunities, actions taken, outstanding balances, dollars recovered, and remaining financial exposure.
- Identify recurring billing, reimbursement, documentation, system, or workflow issues and recommend practical process, reporting, system, or training improvements.
- Partner with Billing, Collections, Payment Posting, offshore support, Pharmacy Operations, Technology, and other teams to resolve discrepancies and reduce repeat errors.
- Provide pharmacy revenue recovery subject-matter expertise, analysis, and recommendations to Revenue Cycle leadership.
- Support development and improvement of Revenue Cycle reporting, controls, procedures, and performance measures.
- Perform other activities assigned by leadership.
Requirements
- Bachelor’s degree, advanced technical training, professional certification, or equivalent combination of education and relevant experience.
- Recommended minimum of 4 years of progressively responsible experience in pharmacy billing, pharmacy reimbursement, third-party claims, revenue recovery, revenue cycle, or a related field.
- Advanced functional knowledge of pharmacy claims and reimbursement with demonstrated ability to independently investigate and resolve complex billing, payment, and payer issues.
- Working knowledge of Medicare Part D, Medicaid, commercial insurance, PBM requirements, coordination of benefits, denials, reversals, recoupments, and related pharmacy billing processes.
- Strong analytical, investigative, organizational, and problem-solving skills, including the ability to reconcile detailed claim and payment activity and identify root causes.
- Proficiency with Microsoft Excel and pharmacy, billing, claims, or reconciliation systems.
- Demonstrated ability to manage competing priorities, exercise sound judgment, communicate effectively with internal and external partners, and follow complex issues through resolution.
- Ability to maintain the confidentiality and security of patient, financial, and business information.
- Ability to perform the essential functions of the position, with or without reasonable accommodation, including applicable physical and environmental requirements.
- Long-term care pharmacy billing, reimbursement, or revenue cycle experience.
- Experience with pharmacy audits, PBM appeals, payer takebacks, recoupments, negative-margin claim review, or revenue recovery activities.
- Experience with FrameworkLTC, Net-Rx, or comparable pharmacy billing and reconciliation platforms.
- Certified Pharmacy Technician (CPhT) or other relevant pharmacy or revenue cycle credential.
Skills
- Pharmacy billing
- Pharmacy reimbursement
- Third-party claims
- Revenue recovery
- Revenue cycle
- Medicare Part D
- Medicaid
- Commercial insurance
- PBM requirements
- Coordination of benefits
- Denials
- Reversals
- Recoupments
- Pharmacy billing processes
- Microsoft Excel
- Pharmacy systems
- Billing systems
- Claims systems
- Reconciliation systems
- Analytical skills
- Investigative skills
- Organizational skills
- Problem-solving skills
- Communication skills
- Long-term care pharmacy billing
- Long-term care pharmacy reimbursement
- Long-term care revenue cycle
- Pharmacy audits
- PBM appeals
- Payer takebacks
- Negative-margin claim review
- FrameworkLTC
- Net-Rx
Experience Level
- Senior
- 4 years of progressively responsible experience
Education Level
- Bachelor’s degree
- Advanced technical training
- Professional certification
- Equivalent combination of education and relevant experience