The Pharmacy Buy and Bill AR Specialist is responsible for managing the accounts receivable (AR) processes related to buy-and-bill medications. This includes verifying insurance coverage, submitting claims, resolving billing discrepancies, and ensuring timely reimbursement from payers. The role requires collaboration with pharmacy teams, healthcare providers, and insurance companies to streamline the revenue cycle and minimize denials.

Essential Functions

Claims Management:

• Submit accurate claims for buy-and-bill medications 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 buy-and-bill medications.
•  Maintain detailed records of payer communications and payment status.
•  Follow up on unpaid or underpaid claims.

Insurance Verification:

•  Confirm insurance eligibility and coverage for buy-and-bill medications.
•  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 buy-and-bill 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 computer 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 identify issues and reports them to their direct supervisor. 
• Maintain regular and predictable attendance. 
• Acts in accordance with CommUnityCare’s mission and values, while serving as a role model for ethical behavior.

Minimum Education: 

• High School Diploma or equivalent (higher degree accepted)

Minimum Experience:

• 2 years medical billing, pharmacy billing, or revenue cycle management, particularly in buy-and-bill processes.