Pharmacy Billing Specialist

About the Role:

Job Code: 43-3021 Status: Full-time, Permanent

Exempt: No Location: Health Services

Department: Business Office Reports to: Accounts Receivable Supervisor

SUMMARY: Under the direction of the Accounts Receivable Supervisor, the Pharmacy Billing Specialist will compile, process and maintain third party billing and accounts receivable for pharmacy in a manner consistent with medical, administrative, ethical, legal and regulatory requirements in the Business Office. The Pharmacy Billing Specialist assumes responsibility for third party billing and accounts receivables, including the timely submission of claims to third party payers, rebilling, posting payments and adjustments, aged/open claims follow-up, and denial management.


  • Responsible for the accurate and timely preparation and submission of insurance claims to third party payers according to Business Office policies and procedures in Script Pro pharmacy software/RPMS system.
  • Responsible for maintenance and control of unbilled claims for accounts receivables.
  • Reviews system generated reports daily to identify claims to be billed/rebilled.
  • Prepares and submits claims to third party payers within a 48-hour time period.
  • Responsible for the re-submission of denied/corrected claims and follow up on aged/open claims according to third party billing guidelines.
  • Documents all claims deemed un-billable (i.e. beneficiaries), along with reasons and supporting documentation required for an adjustment for reconciliation of claims.

  • Verifies and updates patient’s alternate resources in both Script Pro pharmacy software/RPMS system daily to ensure billing of appropriate payer.

  • Post payments in RPMS system and record transaction on A/R log within 72 hours receipt of supporting documentation.
  • Review and process unposted and unallocated A/R collection batches in RPMS system.
  • Reconciles account balances by reviewing records and source documents to identify sources of discrepancies and determine the entries required to bring the account to balance.
  • Review all explanation of benefits and remittances from third party payers for denial management.
  • Processes secondary/tertiary billing after posting payment of original claims.
  • Researches pharmacy insurance rejections and unbilled claims on the pharmacy daily cash report, performs required edits, and rebills claims electronically to third party payers.
  • Processes Medicaid Utilization Threshold Program form for additional scripts as needed.
  • Follows up via telephone with Script Pro/Insurance for technical assistance and resolution of pharmacy billing issues/concerns.
  • Monitor prior authorizations required from insurances on the pharmacy daily cash report and notify pharmacy staff/medical providers of plan requirements.

  • Prepares and mails out alternate resource letters for uninsured patients.
  • Maintains professional telephone etiquette in all contacts with insurances and patients.
  • Maintains up-to-date knowledge of third party payer policies and procedures (including Medicare, Medicaid, and private insurance) and NCPDP standard for claim submission.

  • Compiles data and provides cumulative reports on a daily/weekly/monthly basis as required by Accounts Receivable Supervisor/Business Office Manager/Pharmacist-In-Charge.
  • Trains new/inexperienced staff as needed.
  • Assists in the development and Modification of Business Office policies and procedures.
  • Attends meetings/trainings as requested by the Accounts Receivable Supervisor/Business Office Manager.
  • Scans all documentation in OnBase for Business Office electronic records.
  • Assures HIPAA compliance with regard to billing practices.
  • Other related duties as assigned (including Patient Registration, Third Party Billing and Accounts Receivable).

SUPERVISORY RESPONSIBILITIES: There are no supervisor requirements for this position.

EDUCATION and/or EXPERIENCE: High school diploma/GED and two years’ experience in pharmacy or medical insurance billing. Combination of medical and pharmacy insurance billing experience preferred.

OTHER SKILLS and ABILITIES: Strong oral and written communication skills required. Must have excellent computer skills to use pharmacy/medical billing software, including Microsoft word and excel.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Due to the sensitive nature of information within the Business Office, must maintain strict confidentiality at all times.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

The Saint Regis Mohawk Tribe strives to be an equal opportunity employer dedicated to the policy of nondiscrimination based on race, sex, marital status, sexual orientation, religion, national origin, age, physical disability, veteran status or any other non-job related factor.

The successful candidate must complete a PPD test.

The successful candidate must pass a test for illegal substances prior to employment being confirmed.

The successful candidate must pass a criminal background check prior to employment.

I have reviewed this Job Description with my immediate Supervisor and I understand the contents of it.

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Saint Regis Mohawk Tribe