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Overview

The Manager-Billing and Medical Operations is responsible for the supervision and management of all pharmacy and medical claims processing at Reliance Rx. In this role, the Manager-Billing and Medical Operations will also be responsible for the management of the billing and medical operations teams. This will include monitoring daily workflow metrics and phone metrics, as well as completing daily audits of the billing queues to ensure accurate and timely processing based on payor and internal shipping time requirements. They will assess any claims processing system upgrades and enhancements and ensure best business practices are being followed throughout the company. The Manger- Billing and Medical Operations will not only oversee pharmacy NCPDP claims, but they will also have a high level of experience and knowledge with medical claims processing and 837 set up. They will be expected to work with payors on 837 file development, 837 claim submission, timeliness of submitted claims, denials corrections and resubmission, and payment accuracy. The Billing Manager collaborates with internal departments, payors, and external stakeholders to optimize revenue cycle performance, resolve complex billing issues, maintain compliance with contractual and regulatory requirements, and drive operational excellence. This position is accountable for reimbursement accuracy, accounts receivable oversight, and the continuous improvement of billing processes and systems at Reliance Rx.

Qualifications

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. Specialty pharmacy and copay assistance/foundation billing strongly preferred. Medical billing and 837 claim transaction experience strongly preferred. 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.

Essential Accountabilities

• Oversee all NCPDP claims processing, medical claims submission via 837 and CMS1500, copay assistance billing, and paper claims submission when necessary.
• Subject matter expert on pharmacy benefits vs medical benefits and NCPDP claims vs medical claims. Train team on the differences of each type of benefit/claim.
• Serve as the subject matter expert for all billing issues and development of best billing practices. This will include reviewing escalated billing issues and performing root cause analysis on all billing discrepancies. Responsible for associate follow up, re-training, and disciplinary action when needed.
• Knowledgeable on NCPDP and medical claim responses, including how to resolve rejections and read paid claim responses to identify over/under payments or other reimbursement discrepancies.
• 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.
• Directly accountable for observing and reviewing billing practices at Reliance Rx; providing on-the-fly coaching as necessary. This will include managing and developing the Billing Specialist team and monitoring productivity and performance metrics.
• Oversee patient and insurance accounts receivable for Reliance Rx. Monitoring 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 and facilitate training as needed.
• Lead the submission, maintenance, and management of 837 files and work directly with payors when necessary for implementation and testing.
• Management of all Medical Benefit Orders being administered by providers/clinics, ensure all orders are received ahead of scheduled appointment dates. This will also include working 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.

This is a hybrid position with onsite attendance required at our Williamsville location.

Immigration or work visa sponsorship will not be provided for this position.

Hiring Compensation Range

$76,500 - $95,000 annually. Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

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.

Current Associates must apply internally via the Job Hub.