Billing Manager

Job Description

Job Description

Billing Manager

The Billing Manager is responsible for overseeing and optimizing all billing operations within the specialty pharmacy. This role involves strategic leadership in managing the end-to-end billing processes, ensuring efficient billing, collections, and revenue recognition. The manager will work closely with various departments to improve billing processes, enhance financial performance, and ensure compliance with industry regulations. The Billing Manager will report directly to the Sr. Director of Operations. In this role, the Billing Manager will have access to Protected Health Information (PHI) and Electronic Protected Health Information (EPHI).

Job Responsibilities and Essential Functions

• Revenue Cycle Strategy and Leadership
  1. Develop and implement revenue cycle strategies to optimize cash flow and reduce days in accounts receivable (DSO).
  2. Lead, mentor, and manage the Billing team, including billing, coding, and collections staff.
  3. Collaborate with senior leadership to align revenue cycle strategies with organizational goals.
  4. Implement internal controls related to claims, cash collections and postings to accounting system.
  5. Work with senior leadership on business initiatives and projects as needed.
• Billing and Collections Management
  1. Oversee the billing process for specialty medications, ensuring accurate and timely submission of claims, including serving as delegation oversight official of third-party vendors, if required.
  2. Maintain a vast knowledge of best practices for both medical and PBM billing for specialty medications and home infusion services.
  3. Ensure all PBM and medical claims submitted to payers are accurate and timely.
  4. Monitor and manage collections processes to maximize revenue and minimize bad debt.
  5. Develop and implement best practices for billing and collections to improve efficiency and accuracy.
  6. Coordinate with all internal departments, payers, and partners to generate high reimbursement rates and a low level of denials.
  7. Ensure and assist in efficiently processing and submitting insurance claims for both prescriptions and various pharmacy services, ensuring all necessary documentation is included to expedite approval.
  8. Help resolve rejected or denied claims by carefully analyzing discrepancies, identifying the root cause of the issue, and resubmitting claims as necessary to optimize reimbursement.
• Compliance and Regulation
  1. Ensure compliance with all federal, state, and payer regulations related to specialty pharmacy billing and revenue management.
  2. Stay updated on industry changes, payer policies, and regulatory requirements affecting revenue cycle management.
  3. Create and implement standardized policies and procedures that are accurate, reflecting organization workflows, while also meeting industry standards.
  4. Work with the accreditation team on projects as needed, including annual review of billing policies.
  5. Oversee and accurately and timely perform (when required) claim audits in accordance with policy and procedures to assure the company is compliant with accreditation quality reporting.
  6. Maintain meticulous records of all billing transactions and communications with patients and insurance companies to facilitate transparency and accountability.
• Patient Account Management:
  1. Manage patient accounts comprehensively, addressing billing inquiries, providing detailed explanations of charges, and processing payments in a timely manner to maintain financial balance.
  2. Assist patients in understanding their insurance benefits, including co-payment requirements, deductible obligations, and coverage limitations, ensuring they have a clear understanding of their financial responsibilities.
  3. Establish flexible payment plans tailored to individual patient needs, proactively addressing any outstanding balances to promote timely payments and financial resolutions.
• Financial Analysis and Reporting
  1. Monitor and report on key metrics such as cash collections, unbilled claims, denials, and days outstanding.
• Process Improvement
  1. Identify opportunities for process improvement and implement solutions to enhance the efficiency of the billing cycle.
  2. Work with IT and other departments to leverage technology and automate processes where possible.
• Patient and Payer Relations
  1. Analyze payer contracts including fee schedules to compare reimbursement with drug and ancillary costs.
  2. Address and resolve complex billing and reimbursement issues with patients, payers, and other stakeholders.
  3. Develop and maintain strong relationships with payer representatives to facilitate smooth claims processing and dispute resolution.
  4. Review financial hardship applications and present to leadership.
• Training and Development
  1. Develop and conduct training programs for billing staff on billing practices, compliance, and industry updates.
  2. Ensure ongoing professional development and certification for billing team members.

Required Qualifications

• Bachelor’s degree in Finance, Accounting, Healthcare Administration, related field, or relative work experience.
• Computer proficiency and technical skills with Microsoft Suite products, revenue cycle
• Minimum of 5 years’ experience as a leader in billing or reimbursement role
• Management software & electronic health record systems experience
• Excellent verbal and written communication skills
• Strong understanding of specialty pharmacy operations, billing practices, payer requirements, and regulatory compliance
• Soft skills required:
  • Team Leadership: Ability to inspire and guide a team, fostering a collaborative and productive work environment.
  • Conflict Resolution: Skill in addressing and resolving disputes or issues within the team or with external stakeholders.
  • Mentoring: Capacity to coach and develop staff, providing feedback and support for their professional growth.
  • Interpersonal Communication: Proficiency in interacting with various stakeholders, including patients, payers, and other departments.
  • Presentation Skills: Ability to convey complex information clearly and effectively to executive management and other key stakeholders.
  • Active Listening: Skill in listening to understand concerns, feedback, and needs, and responding appropriately.
  • Decision-Making: Ability to make informed, data-driven decisions that align with organizational goals.
  • Innovative Thinking: Capacity to think creatively and identify new approaches to improve revenue cycle performance.
  • Negotiation Skills: Ability to effectively negotiate with payers and other stakeholders to resolve disputes and secure favorable terms.
  • Accuracy: Meticulous approach to reviewing billing, coding, and compliance to ensure correctness and prevent errors.
  • Quality Focus: Commitment to maintaining high standards in all aspects of the revenue cycle process.
  • Adaptability & Flexibility: skilled in adapting to industry changes, regulatory updates and organizational shifts while maintaining an ability to remain effective under pressure and managing stress in fast paced environments.
  • Empathy: Ability to understand and address the needs and concerns of patients and payers with compassion.
  • Service Excellence: Commitment to delivering outstanding service and support to internal and external stakeholders.
• Language Skills: Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
• Mathematical Skills:Ability to solve simple math problems and analyze numbers as they relate to necessary job functions.
• Reasoning Ability: Ability to define problems, collect data, establish facts, and draw valid conclusions.

Physical Requirements and Screenings

The physical demands described here represent those that an employee must meet to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

The following are the minimum requirements of all employees of Heritage Specialty Pharmacy.

• Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  1. Must be able to lift and carry 20 pounds.
  2. While performing the duties of this job, the employee is regularly required to sit and talk or hear.
  3. The employee is frequently required to stand, walk, use hands or fingers to handle, or feel and reach with hands and arms.
  4. Specific vision abilities required by this job include close vision and ability to adjust focus.

Travel and Work Location

• This position is an in person, hybrid or remote role. As such, the employee is required to work and be available during regular business hours to allow for the highest level of collaboration with other departments.
• Travel between Summit Holdings XI offices in Lee Summit, MO as required to execute job responsibilities listed above.

The job description and list of duties indicated above is not comprehensive. Duties, responsibilities, and activities may change at any time.

EEO Statement

Heritage Specialty Pharmacy is an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and welcome applicants from all backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other protected status under applicable federal, state, and local laws.

Monday-Thursday 8:00am-5:00pm CST, Friday 8:00am-3:30pm CST